Over the years I’ve written many articles about what takes place internally to review and make liability decisions concerning disability claims. A quick snapshot of these activities includes referrals to internal resources to obtain file documentation, consistent and repetitive chasing for more and more medical information, surveillance and field representative requests, internal medical reviews, roundtables, setting of resolution dates, check cutting, flups (diary system follow-ups), and many other internal reviews and activities deliberately intended to “stack the deck” against the payment of claims. These activities are on-going and claims specialists are performance managed as to how well he/she continues to route the claims through an endless maze of paperwork, reviews and upkeep. Internal review processes never end.
As long as the insured is receiving monthly benefits, the insurance company will continue to investigate the claim; the review process is forever on-going and the insured is subjected to request after request for more and more information to justify the payment of benefits. I am often asked, “Is there ever going to be a time when I can relax and be assured of the payment of my benefit?” And, the answer is no. As long as the insurance company believes it can deny the claim, the “risk management” of the claim will continue.
Is the insured a victim of an uncontrolled disability claims process seeking the denial of benefits? Not at all. However, one thing is certain. If left to its own devices and strategies paid for by millions of corporate dollars, the insured may not be successful in defending the policy contract or his/her own medical point of view. Insureds have contractual rights under the policy and can enforce those rights on those occasions when the insurer misinterprets the language, or attempts to force the insured to act in administrative ways for which there is no duty to act.
In order to defend a disability policy contract, the insured should read it, and understand it. One attorney told me recently she read a disability policy and had difficulty understanding it even at her level. Group Plans provided by employers should be obtained and read immediately upon enrollment and effective dates of coverage. If the policy or the process of filing a claim isn’t clear, the employee should make an appointment with the benefits representative in HR and go over the policy long before an unforeseen disability occurs. One cannot defend his/her rights under any disability contract policy unless the provisions are clearly understood and documented.
Claims specialists and managers view challenges to their decisions and communications as personal affronts to their “authority.” Unfortunately, many, many insureds are intimidated by rude and abrasive insurance employees who give the impression their decisions are final. The truth is, most claims specialists are not the sole determiners of claim decisions and can be held accountable by the insured for errors and misinterpretations of policy and other information. “Push back” is certainly allowed from the insured.
There is an old saying that whomever or whatever controls a person’s money also controls that person. I’ve found this to be a true statement. Because insureds desperately “need” the financial benefit in order to live and pay bills, the insurance company is able to instill fear, even to the point of exaggeration and dishonesty. Insureds often feel helpless against a tyrant who continually threatens to remove financial support at at time when he/she is helpless, ill, powerless, and vulnerable. Disability insurers understand the “fear factor” quite well and use it to their advantage.
Insureds and claimants should strive to maintain control of the claims process and “push back” when communications and decisions are found to be misinterpreted and dishonest. Allowing any disability insurer to have a consensus of opinion about anything is cause for disaster. Insureds need to be proactive in the management of their disability claims and there are many ways to communicate with physicians, employers, regulators, and others who have input or oversight into the claims review process. The insurance company knows too that disabled persons are often too ill and exhausted to put up much of a fight and many claims are denied successfully for this reason alone.
Medical information can be kept up to date; daily journals should be maintained; logs of communications can be documented; social security files can be obtained; written complaints can be made to federal and state regulators etc. In the absence of an organized and deliberate attempt on the part of the insured, or his/her representative, the insurance company will always make claim decisions in its own best interest. Unfortunately, many insureds make it easy for the insurers to document a claim file with information from resources it obtains without having anything in the file supporting the claimant’s disability and points of view.
Anytime insureds and claimants allow a disability insurer to enact, control, and document its own self-interest in NOT paying benefits, claims will likely be denied at some time in the future. Foxes in the hen house eventually consume the “hens” not vice versa. The disability claims process lends itself to abuse and conflicts of interest at every turn. Without the insured’s persistent “push back” and oversight the insurance company will continue to instill fear and intimidation.
Remember, in today’s terms insureds and their employers pay insurance premiums for the privilege of assuming the risk of disability income replacement. This “assumed risk” means that the insured now risks whether or not the disability claim will be paid instead of the insurance company assuming the risk of paying some claims and not others. Simply put, insureds today pay a premium for assuming their own risk of having benefits paid when they need them. Insurance companies can’t assume risk if they aren’t paying claims, or are placing an unfair burden on insureds to provide more and more documentation before claims are paid. In a sense, the sale of disability policies is an unfair and misrepresented sale because the insured is paying a premium to assume his/her own risk.
Insureds need to be reminded on occasion that despite the fear of becoming financially destitute they too have rights. Disability insurers are managing disability claims 24-hours a day. What are you doing to protect your benefits? All disability claims require management and the exercise of control when the process becomes distrustfull and miscommunicated.
