They Have You By The Kishkes – A Sunday Editorial

FearHave you ever heard the old saying, “Those who control your money also control you?” Although one could say this applies to most occasions in life, it is particularly true of private disability claims and the extent to which insurers use FEAR to transform disabled persons into dollar sign profits.

Lately, I’ve been hearing nervous insureds saying, “I don’t want to do anything to jeopardize my claim because I need the money.” Obviously, those who are receiving benefits fully recognize the “control” insurers have over them and are willing to do anything to ensure the “checks are in the mail.” Unfortunately, doing everything the insurance company asks does not a successful paid claim make.

In fact, in my experience those who refuse to “push back” and defend their claims, Plans and policies are more likely to end up with zero benefits at the end of the month. Saying nothing, doing nothing, OVER SPEAKING claims, and providing as much information as possible is a dead ringer for denied benefits.

Fear causes people to do and say things they normally would not do. The elephant in the disability room is that insureds and claimants need and want to be paid benefits, and insurers do not want to pay them. In the end, from both perspectives, it’s all about the money.

Sometimes insureds ask me, “Should I see this specialist?”, or “Should I have this test to keep my benefits?” Putting treatment and continuously changing medical care just to keep benefits coming in is a prime example of how far insureds are willing go to ensure the money keeps coming in.

My answer to these types of questions is that those who are disabled should put their health and well-being as the first priority and let the claim fall into place after.

Disability insurance policies, ERISA in particular, are adverse to claimants from the very beginning. Plans contain 24-month changes in definition, 24 month mental and nervous limitations, offsets, self-reported and subjective provisions, appeal timelines and discretionary authority. One could easily say that insurers have claimants by the cojones from the very beginning.

Not pushing back to defend what little rights you have doesn’t mean benefits will be paid to maximum duration. In fact, those who appear a bit too willing to cooperate and are over accommodating often creates red flags that buys the lion’s share of risk management activity such as surveillance, field visits etc.

Another example is the fact that insureds and claimants continue to speak on the phone with insurance representatives thinking, “they HAVE to.” Actually, there is no disability policy I’m aware of that requires insureds to speak verbally with any disability claims handler on the phone. (Have you read your Plan or policy? It’s true.)

Yet, I still receive calls from those who say, “I just spoke with my claims handler….I told my claims handier something and now I’m in trouble….My claims handler was so rude to me…..They asked me why I don’t just go back to work…..”

Disability claims “Best Practices” is for insureds and claimants to request all communications in writing. Those who are taking prescribed pain medications, opiates, or depression drugs should NEVER speak verbally with insurance representatives anyway.

One of the best ways to “defend” ones rights under a disability Plan or policy to ask for all communications in writing so that there is never a dispute as to what is said, requested, or documented in the file.

Nevertheless, fear causes many insureds to continue to OVER SPEAK claims on the phone by giving far too much information that can be used against them in the future. A large percentage of claims are denied citing “you said…….” as the reason.

Since disability claims are adverse to begin with, it makes sense that all insureds and claimants should defend their rights under Plans or policies by “pushing back” when  claim requests are burdensome, overbearing or harassing. I’m not talking about coming across as aggressive or arrogant, but politely setting the standards as to what is appropriate claims investigation and what is not.

Challenging medical “misrepresentations”, and “snatching” medical information from patient notes favorable to insurers while ignoring all else favorable to insureds should always be challenged and corrected for the record.

Not speaking up to defend what’s right is a sure way to a claim denial. Since private insurers have you by the “kishkes” anyway, it’s always a good idea to speak up and use what clout you have to protect your benefits from unfair denial.

Giving in to every request, every unfair demand, every out of contract misrepresentation doesn’t assure anything but a swift kick in the guts from insurers  who do not want to pay you.





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