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Your disability insurance claims examiner is not their friend and the information you provide to them can often be misrepresented and used against you.

Your disability insurance claims examiner is not their friend and the information you provide to them can often be misrepresented and used against you. It is essential to remember that insurance companies have an inherent conflict of interest in that they are responsible for making the decision on whether you are eligible to receive benefits and they are the party responsible for having to pay the benefit if you are approved. Ultimately, insurance companies are for-profit businesses that earn money by denying claims. For this reason, disability insurance claims are highly scrutinized and often fiercely litigated. Claims examiners work for insurance companies and they are trained from the beginning to ask questions in such a way to elicit certain information. No matter how pleasant and caring they seem, they are not there for your benefit. While your claims examiner may actually be sympathetic to your condition, their hands are tied by the insurance company. Each insurance company creates their own rules and procedures which, claims examiners must follow to "investigate" claims. Their work is closely monitored by supervisors, conversations are often recorded, and they are expected to follow protocol. Accordingly, it is essential that you are not caught off guard or lulled into giving answers that can be misconstrued or taken out of context. This is one of the most common insurance company tactics.  Be aware that what you say and how you say it can be used against you and that your claims examiner has been trained to seek out certain responses and to evaluate information provided in a light most favorable to their employer. 

This economy has affected everyone, including businesses like your insurance company. Accordingly, more and more disability insurance claims are being denied at the initial stage and terminated after an approval. When applying and/or maintaining a claim for disability benefits under your insurance policy, it is imperative that you provide sufficient information regarding your claim and that you are extremely careful to provide the information in a way that cannot be manipulated or misrepresented. Here are some tips on how to do this:

  1. Make sure that your physician is accurately and extensively documenting your condition and symptoms. Physicians write reports for themselves and other physicians. They do not usually do this with an eye towards your disability claim. Thus, physicians do not always document your diagnoses or your common symptoms on every report. However, insurance companies will often point to these records to suggest that there is no evidence that you suffer from debilitating symptoms on a continuous basis. It is essential that your physician understand the importance of thoroughly documenting your symptoms every visit.
  2. If your insurance company has not asked for updated or additional documentation, do not assume that none is needed. It is your obligation to continuously supply information to support your claim. Often, an insurance company will only send claim forms to a claimant and their physician without a request for records. Unknowing claimants are often lulled into believing that as long as these forms are completed, that is all that is needed to support their claims. Unfortunately, many of these claims are denied based on a lack of sufficient evidence. Don't assume that you will get a warning that something is missing or receive a request for updated records. Send in your medical information on a periodic basis and ask the claims examiner if they need anything else for your file.
  3. Review all of your records before you send them in, so that you can determine if they are accurate. Also, it is important to know exactly what your claims examiner knows so that you can answer questions and recognize when information is being taken out of context.
  4. Ask the claims examiner if you can record the conversation or have someone on the telephone to help you get out important information and to take copious notes. Many claimants have difficulty remembering important information to tell their claims examiner and often forget what information was discussed during these conversations due to severe pain and medication.
  5. Do not talk to your claims examiner without preparing first. Often claims examiners will call without an appointment. You can tell them that you are not feeling well and will have to call them back. Before you call back, review your information, and write down important symptoms, physician appointments, test results, and other issues. Also, as indicated earlier, it is always a good idea to get permission to record the calls or have someone else on the phone.
  6. Do not give details about where and when you go outside of your house. It is important to be honest and let your insurance company know what you can and cannot do, but giving very specific details about your routine will merely aid the insurance company in setting up surveillance of you.
  7. Do not speak in absolutes. Never inform the insurance company that you NEVER go out or NEVER do something. The likelihood is that you occasionally run errands, go to doctor's appointments, and go out to eat. This does not mean that you are not disabled. Remember claims examiners are trained to ask questions in such a way to elicit certain responses. Do not be tricked into stating that you NEVER do something, when you really mean that it is difficult, causes increased pain and therefore you cannot do it continuously, or you rarely are able to engage in an activity. Your insurance company will likely place you under surveillance until they see you do that activity and then claim you were lying.
  8. Do not forget to tell your claims examiner about the effects of your medications and make sure your physician is documenting any side effects you are experiencing.
  9. Avoid volunteering too much information, unless it is to clarify a misunderstanding or misrepresentation by your insurance company. Everything you say is being documented.
  10. Be careful when talking about depression if your disability is based on a physical condition. Under many policies, benefits are only payable for a limited period of time if a disability is based in whole or in part due to a psychological condition. Accordingly, insurance companies often attempt to classify disabilities as psychological conditions just because the claimants also experienced some degree of secondary depression.
  11. Give examples of your limitations to illustrate what you cannot do. Explaining that you have to stop to stretch twice on your hour drive to your physician's office due to pain illustrates your limitations better than simply stating that you cannot sit for more than 20 minutes at a time.
  12. Do not offer to go to a physician chosen by your insurance company. Typically, these physicians are not "independent" and are paid a substantial amount of money to perform these examinations for insurance companies. If your insurance company, on its own, requests that you attend an examination by their physician, you should not refused to go to the examination. However, there are things that you can do to try to even the playing field, like have the examination videotaped, going to your own independent examination in addition to the insurance company's evaluation, and/or trying to get your insurance company to choose a more neutral physician.
  13. Have your friends, family members, and co-workers provide statements regarding your condition, limitations, and symptoms. However, make sure that they follow the tips listed above.

At Disability Insurance Law Group, we work closely with our clients, their physicians, and their witnesses to make sure that the right information is in the file. We never allow our clients to speak with their claims examiner or insurance investigator without our presence. We also obtain our own independent medical examinations and thoroughly investigate the insurance company physicians.

Due to the economy, more and more disability claims are being denied at the application stage and terminated after an approval. It is essential that you understand your rights and obligations under your policy and the law. Remember, your disability insurance claims examiner is not their friend and the information you provide to them can often be misrepresented and used against you.

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