Individual or Group Disability Policy
Whether you have an individual long-term disability policy that you purchased from an insurance agent or a group disability policy provided by your employer, the application process requires the same attention to detail.
An application for disability income benefits must contain specific information and be supported by the proper documentation. The application process involves a collaboration between the applicant, the treating physicians, possibly an accountant and any co-workers at the time the applicant became disabled. The disability application requires an applicant’s occupational duties to be specifically broken down into categories and the amount of time spent performing each duty must be established. The manner in which this is determined can make the difference between receiving total or only partial disability benefits. In order to verify occupational duties, an insurance company will want to analyze the applicant’s tax returns, pay-stubs, profit and loss statements, appointment books, monthly and annual CPT code production reports (physicians only) and any other documentation that shows the work the applicant has performed during the three years prior to filing a claim and the time period after filing a claim.
Next the insurance company will require the applicant’s treating physicians to submit Attending Physician Statements, which must state whether or not the applicant can perform either the duties of his or her occupation or in some instances, the duties of any other occupation. In addition, the insurance company will either call or meet with the treating physicians in order to discuss the applicant’s claim for disability benefits. We regularly consult with an applicant’s treating physician, so that the treating physician can properly evaluate an applicant’s restrictions and limitations in conjunction with the applicant’s daily occupational duties. In most cases, disability should not be addressed in a generic sense, but in relation to the applicants own occupation. Disability insurance claim examiners are trained to look for specific information in the medical records, and if information is missing they will rely on a lack of information to deny or delay claim approval.
While evaluating the applicant’s claim for benefits, the insurance company will usually send out a company field representative to interview the applicant and review any financial documentation in the applicant’s possession. Field representative interviews should never be conducted without the presence of an attorney. How you phrase a response will follow you throughout the claim’s process. In addition, the applicant may be required to appear for an independent medical examination (IME) and a functional capacity evaluation (FCE). In order to protect the rights of the applicant and ensure legitimate testing, we always recommend that these so-called independent medical exams are videotaped and a copy of the report is provided to the applicant upon completion.
Lastly, without the applicant’s knowledge or consent, the insurance company will usually have a private investigator follow the applicant and conduct video surveillance for several days. The insurance company will then send the video surveillance to the independent medical examiner or the claimant’s own doctors in order to determine if the observations in the video are consistent with the applicant’s stated inability to perform the duties of his or her pre-disability occupation. We always ask the insurance company for a copy of the surveillance video and to give the applicant’s treating physicians an opportunity to review the surveillance video before any claim decision is made.
The insurance companies are not entitled to every piece of information they request, and an applicant must be aware of the legal implications of every communication and document requested by the insurance carrier. Insurance companies have a lot of discretion under the terms of a disability insurance policy. They are required to focus on the limitations and restrictions which prevent an applicant from performing his or her occupational duties at the time the disability started. Determining the date of disability is often difficult, yet it must be selected in coordination with the supporting medical records. The playing field is not equal. Unfortunately, the insurance carrier is the wolf in sheep’s clothing.
If you are considering applying for benefits or are waiting for a decision, contact Attorneys Dell & Schaefer for a free evaluation of your claim for disability benefits.