Disability Income Insurance Claims

The material on this Web Site is not legal advice. The material is strictly for informational purposes.  Your visit to this Web Site does not create an attorney-client relationship of any kind. (Full Disclaimer)

A: Although different companies use different language in their policies, generally a claimant must establish (1) that he/she has a documented, legitimate medical condition, which is certified to by a competent medical provider; and (2) as a result of this condition he/she is unable to perform their substantial and/or material occupational duties. A claimant must meet both of these criteria before being eligible for benefits.

A: Yes. Most insurance policies provide for very clear requirements on giving timely notice to the carrier of such a claim. In the event that you fail to give timely notice of the claim, you run the risk of the carrier denying the claim because the insurer was not given adequate and timely notice to investigate the claim. In most cases, unless there is real prejudice shown to the carrier as a result of the delay, these types of issues will not be determinative as to a legitimate, properly documented claim. But it is important to act quickly to put the carrier on proper notice as soon as you know that you are going to file a claim.

A: Immediately. Disability income claim forms are not like health insurance claim forms. A lot of thought and care should be exercised in answering the very specific questions required by a standard disability income insurance claim form. Don't forget once you submit a claim form, you must live with the information and positions you have taken in that form. Your claim forms become the "law of the case" and, except for exceptional circumstances, your disability income insurance claim stands or falls with those initial claim forms. To avoid obvious mistakes and pitfalls which can result in delay or even denial of legitimate claims, you should get a knowledgeable and experienced disability income insurance attorney to assist you in preparing your first claim form before you send it to the carrier.

A: This depends in part on whether the policy is a group policy covered by the Employee Retirement Income Security Act ("Erisa"), or is just an individual private disability income policy between the carrier and the insured. Generally speaking, the Courts allow carriers to take a "reasonable" time to fully investigate a claim before making a claim determination. What constitutes a "reasonable" time will depend in large measure on the particular facts of each case. In Erisa cases, carriers generally have 90 days to decide a claim, but this time period can, and often is, extended for specific reasons.

A: Yes. No disability income insurance company will pay a disability claim unless a competent medical provider has certified to your disability and its impact on your ability to do your job.  The doctor has to do much more than "sign off".  The physician must not only describe your illness or injury in detail, but he or she must explain to the insurer why the illness or injury prevents you from performing your job duties.  And, the physician usually being quite busy, getting the necessary medical reports requires the skills of an attorney who has obtained them before from a variety of doctors.

A: Once you are on long-term disability, most policies provide for a "waiver of premium" which permits you to stop paying the monthly or quarterly premiums due for these policies for the duration of your disability. Once your disability is over, you will again begin to pay premiums, but you will not be required to pay premiums retroactively. Be certain to check the terms of your disability income insurance policy in these circumstances.

A: Most disability income policies require insureds to submit to an Independent Medical Examination (IME) by doctors selected by the carrier to confirm the diagnosis and the state of impairment. Some also require a Functional Capacity Evaluation (FCE).  Generally speaking, insureds who do not agree to participate in this process risk losing their benefits. However, the insured does have certain rights with respect to the conduct of those IMEs and FCEs.  These rights include the right to have a witness present, including an attorney,  to record

the session itself, and to get copies of the reports and underlying test results. Insureds also have the right to have these IME and FCE exams scheduled at a convenient time and place, and only as frequently as is reasonable under the circumstances.

A: Yes and no. Depending on the type of policy you have and the state in which you reside, you may have state law rights which allow you to have your legal fees reimbursed by the carrier if you win. Most states do not provide for these rights for private disability insurance.  But, if you recover punitive damages for a carrier's "bad faith" claims practices your legal fees will most likely be covered.  However, if your claim is under a group policy covered by Erisa, such as an employer sponsored disability income insurance plan, you are entitled to have your legal fees reimbursed by the carrier if you are successful in litigating your claim. 

A: Not before a knowledgeable lawyer thoroughly reviews the offer from your point of view.  Insurance carriers rarely do anything voluntarily unless it is in their financial or legal best interests.  Whether to accept a buyout offer is a complex issue which must be  thoroughly analyzed by some one who completely understands  the real value of these types of disability income policies.  All pertinent factors which bear on such a decision must be carefully considered.  Be wary of carriers which try to get out from under your claim cheaply by tempting you with what appears to be a sizeable sum when you are hurting and are financially strapped.  Under these circumstances the buyout offer may be totally inadequate!

If you have a question which was not covered in the FAQs above or would like more information about any answer,

Contact Mike or call toll-free at (800) 797-5575.

The material on this Web Site is not legal advice. The material is strictly for informational purposes.  Your visit to this Web Site does not create an attorney-client relationship of any kind. (Full Disclaimer)