Top 5 Denial Reasons for Disability Insurance (ERISA Lawsuits)

Once a policyholder receives a denied disability claim, it can be very difficult to have it overturned, so you want to understand as much as possible about the process from the very beginning.

Number One: Private Investigators

When compiling the top-five list for claim denials, disability lawyers have identified the number one reason as being private investigators with surveillance video cameras. It happens all the time, she states, that policyholders Law Firms being followed and recorded without their knowledge.

“The insurance company will hire private investigators to follow the claimants for two days, three days, four days, depending whatever they think is appropriate to see if the claimant is doing anything that they claim they couldn’t do on their application or told their doctors they couldn’t do.”

The private investigator compiles a report, which includes a video of the policyholder. For example, if a man has claimed that he needs a cane in order to walk, a video can catch him walking around the mall without it. The insurance company feels justified then in deciding, with evidence, that the man has lied about his inability to work, thereby validating the disability insurance claim denial.

Number Two: Medical Examinations

The second most common reason that claims are denied is compulsory medical examinations. Some policies contain language that allows the insurance company to send the policyholder for an examination by doctors or therapists who have been hired by the company.

These examinations fall into one of two categories, one of which is more intensive than the other.

· The IME Exam is the shorter of the two, and it stands for Independent Medical Exam.

· An FCE is a Functional Capacity Evaluation, which can take three to four hours to complete. It measures a person’s ability to work.

A good majority of claims are denied afterwards, because these doctors, who are paid by the insurance companies, write reports in their favor.

Number Three: Definition of Disability

The third instance in which policyholders receive a denied disability claim is when there is a change in the policy definition. Most policies have a 24-month “own occupation” period in which a claimant must only prove that he cannot perform “his own” prior occupation. But after 24 months, the policy can then convert to what is known as an “any occupation” period. This requires the claimant to prove that he cannot perform “any” work at all.

Disability attorney digs a little deeper into the subject by explaining that an “income component” can come into play at this point. When the claim enters the “any occupation” phase, some policies allow that the job has to pay at least 60 or 80 percent of what the claimant previously earned. However, other policies can state instead that the job could be “any gainful occupation” that the person could perform, similar to a social security disability standard.

“After the 24 months expires, it becomes another standard of disability”. “And it’s a much more difficult definition to fit into because what you’re trying to show the insurance company is that you can’t do even sedentary work, sitting at a desk all day long.”

As it nears this 24-month mark of the definition change, usually at about six to nine months prior, the insurance company starts looking at whether the person will be eligible for the next phase or if they can finally deny the claim altogether. That’s when they start doing things like sending out the private investigator or scheduling the IME medical examination.

Number Four: Improper Documentation

Coming in at number four in the list of most common reasons for disability claim denials is improper documentation by the claimant’s physicians. The doctor is often rushed and doesn’t take time to write careful and detailed notes showing that the patient is disabled and has limitations because of his condition.

The insurance company can also take advantage of a physician’s note saying that the claimant was having a good day without pain. Even though there may be 30 other recorded notes indicating pain, they can use that one notation of “no pain” as validity for denying the disability claim.

To avoid this happening, the policyholder can do two things:

Communicate to his physician the importance of documenting any restrictions and limitations, and that failing to do that will cause the patient to lose his disability income.

Look at his transcribed medical records at least once a month and get a copy of the records for each visit.

Number Five: Mistakes on Claim Forms or Applications

The fifth most common reason for a denied claim involves simple mistakes. It is very common for a policyholder to make mistakes on a claim form or original insurance application. The significant drawback when this happens is that once improper information enters a claim form, it stays in the record permanently, giving fuel to the claim denial.

The attending physician typically gives claimant statements to the insurance company during the course of the claim, which can be issued once a month or every six months or so. There can be mistakes on those as well.

“I’ve seen things as simple as the boxes – how many hours in a day can the person can sit – and the doctor checks six hours or eight hours, when the person can’t even sit for two hours.”

How to Avoid These Five Most Common Mistakes

One useful way to avoid common mistakes leading to a denied disability claim is to hire a knowledgeable disability insurance attorney to represent you with the insurance company. Disability insurance lawyers can work with the claim forms from the very beginning, making sure there are no mistakes before sending them to the insurance company. This includes reviewing doctor files and getting corrections, clarification and details of the disability into the original claim record.

A disability insurance law firm may also offer a monthly claim-handling service in which a disability attorney takes the burden off the claimant, who may be sick and/or inexperienced in handling a disability insurance policy. The lawyers review all medical records, claimant statements, attending physician statements, and all communications to and from the disability carrier.

Regardless of whether it’s an application, a monthly claim handling issue, or if you’ve already been denied and need an ERISA appeal or ERISA lawsuit, experienced disability lawyers can help. Contact the AZ Hometown Lawyers if you’ve been denied disability insurance at 602-495-1005.

CREDIT: Gregory Dell

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