Guidelines for Filing Long-Term Disability Insurance Claims

This article is provided by the Law Offices of John E. Dunlap, P.C.  to assist you in the insurance claims process.  It is not a substitute for legal representation.  Every claim is different, and only by employing a lawyer do you fully protect your rights.  If you have questions about your long-term disability, please call our office at (901) 320‑1603 or email us on our web site.

Locate the original and any addendums of your policy.  Maintaining good records of your contracts is essential, should you need to go to an administrative appeal or litigation.  Do not rely on your employer’s human resources department or insurance carrier to provide those contracts.

Do not try to represent yourself.  Working with an attorney who is experienced in handling these type of claims could mean the difference between a properly prepared claim and one that gets denied.

Monitor dates and deadlines.  If your policy requires a 90‑day filing of proof of loss, make every effort to be several days or even weeks ahead of the curve.  Filing even a day late could turn a claim into a denial.  Moreover, send all correspondence to the insurance company by certified mail and make certain you keep all copies for your own records.

Medical records are probably the most important part of your claim presentation.  You have a right to have a copy of all your tests, records and reports and you need time to review them.  If there are things you don’t understand, ask your treating physician.  If your doctor does not provide a satisfactory answer, obtain another opinion.  If there is information that does not seem correct to you, insist on discussing it and if necessary, request that corrections be made in the proper manner.

Treating doctors are not insurance professionals or lawyers and do not understand many of the elements in determining claim decisions.  Medical records must clearly indicate limitations and restrictions and relate specifically to your occupation and should clearly describe how these problems prevent you from performing tasks necessary to do your job.

Medical records must include documentation that could also serve as evidence of your inability to perform the necessary task associated with employment, whether it’s physical labor or sedentary employment.  Insurance adjusters often fail to consider the cognitive requirements of work, so you must present these aspects of the job.

Every time you have contact with the insurance company, be careful.  Always make detailed notes on who you spoke with, the date, time and details of the conversation.  If necessary, have a friend or professional on the phone or in the room who could serve as a witness on your behalf.  Tell the insurance company representative another person is on the phone line with you and make a note that this has been made clear to all parties.  After each phone conversation, send a letter that describes the conversation and all details.  In the letter by requiring the insurance company to respond if they disagree with the details.

Protect your claim.

No matter how friendly the insurance adjuster may be, they are not your friends.

Filing a disability insurance claim can often result in the possibility of surveillance and review of any material you post on social media.  If your claim involves being unable to travel to get to work, you may be videotaped if the investigator sees you traveling.  If you call the adjuster from a phone not located in your home, caller ID can be established to prove you are able to travel.  Today’s insurance company watches public posts, forums, bulletin boards, chat rooms, social networking sites and any online sources where information can be gathered.  Our office recommends that people refrain from using Facebook or Twitter while the claims process is ongoing.

Filling out insurance forms is much like a lawyer preparing for trial in that every piece of information is a chance to build or destroy your claim.  Always be honest, but do not leave yourself exposed to evidence contrary to what you have stated.  If you have days where you do not feel sick or disabled, be prepared to state how many days a week you’re able to function.  If the disability leaves you unable to do much of anything except between 10:00 a.m. and 11:00 a.m., state this.  If the forms are not long enough, make a note on that form that clearly indicates more information is on the attached page.

If the insurance company instructs you to go for an Independent Medical Examination understand that you are going to be examined by a doctor who is employed and paid for by the insurance company.

If you are ordered to go for a Functional Capacity Evaluation, review your policy to determine if this test is specifically in the language of the policy.  These tests are not necessarily required, and they are often not accurate.  If you do go for the test then you are asked to perform a task you know you cannot do without pain or discomfort, do not do it.  Be certain to document how you feel following the testing, and consider seeing your treating doctor shortly after the test for further evaluation.

The Importance of Owning Disability Insurance

A large number of Americans believe that they will never become disabled despite statistics to the contrary. An article from the Bureau of Labor Statistics reports that in 2014, only 34 percent of private industry workers participated in their employer’s Long Term Disability Insurance program.

Compare that number to the likelihood of becoming disabled during their working lifetime:

A typical male, age 35, 5 foot 10 inches, 170 pounds, non‑smoker, who works an office job, with some outdoor physical responsibilities and who leads a healthy lifestyle has a 21 percent chance of becoming disabled for 3 months or longer during his career; with a 38 percent chance that the disability would last 5 years or longer and with the average disability for someone like him lasting 82 months.

A typical female, age 35, 5 foot 4 inches, 125 pounds, non‑smoker who works an office job, with some outdoor physical responsibilities and who leads a healthy lifestyle has a 24 percent chance of becoming disabled for 3 months or longer during her working career; a 38 percent chance that the disability would last 5 years or longer, and with the average disability for someone like her lasting 82 months. According to these statistics, 67 percent of American employees are at risk if they should become disabled and unable to work. Our office recommends the following:

  • If your employer offers disability insurance, participate in the program. Social Security disability benefits can take years to obtain in many instances.
  • If your employer offers disability insurance and you have a policy, consider buying a private policy. If you have a certain lifestyle that you would want to maintain, chances are very good that the policy from your employer will not be enough for more than subsistence levels.

If your disability insurance has been denied, delayed or terminated please call our office for a free consultation.