The Importance Of Having A Copy Of Your Policy And Knowing What It Says

I recently spoke with a woman on the phone who had several questions concerning her claim. Although most of them had to do with a Unum field visit, in the course of our conversation I discovered she had not requested a copy of her policy and had no idea what it said.

I think my readers would be amazed to know how often insureds tell me they don’t have their policies and have never read them. My response is always the same, “How can you defend what you don’t have or know about?”

To begin, the only relationship insureds and claimants have with insurers is what is written and contained within the official Plan or policy. The “contract” per se describes duties and responsibilities for both claimants and insurers, and both parties are expected to abide by policy provisions in the administration/management of claims. How many claimants have voluntarily submitted to a field interview because they had no idea it wasn’t required in their policies? Why would anyone do that?

Although most insurers have now closed the field visit loophole by including provisions requiring field interviews in the. newer policies there are older policies that omit the requirement. Therefore, the first thing to do when asked to submit to a field interview is to “check the policy or Plan to make sure the contract requires you to do it.” How can you do that when you don’t have the Plan or policy and haven’t read it?

Yes, all disability contracts either specify directly or allude to the fact that claimants are expected to cooperate. However, insureds can, of course, cooperate in writing as well as they can on the phone, or directly in a field interview. Insureds and claimants have no contractual responsibility to do anything that isn’t written into the Plan or policy document.

Filling out forms and questionnaires and other administrative information gathering requests ARE in the policy under the capstone phrase, “proof of claim.” All ERISA claimants and insureds have a responsibility to obtain copies of their “Certificate Booklets and SPD (Summary Plan Descriptions), and have a clear understanding of what duties the insurer has, and what duties insureds have.

Therefore, when ERISA claimants are faced with unreasonable deadlines and timeline requests, responses can be placed in the record documenting a 10-day request for records, for example, is out of contract. Most Plans allow 30-45 days to provide continuing proof of claim.

Some insureds give insurers much more power than they actually have because they are afraid. But, if claimants are so afraid of not getting paid, wouldn’t it be more prudent to obtain copies of the Plan or policies and know what the provisions are?

It is very important for all those covered by private disability insurance to obtain copies of the document under which they qualify for benefits. It has never made sense to me that insureds file disability claims and remain knowledgeable as to what the rules are.

DCS, Inc. always performs Plan or policy audits to ensure clients are meeting their duties and responsibilities under the Plan. And….that insurers are not engaging in any out of contract demands.

Both claimants and insureds have rights under their disability Plan or policies and I’ll say again, “You can’t defend what you don’t have, or know about.”

Filed under: Policy Reviews, Policy School
Source: Linda Nee