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Don’t Derail Your Disability: Tips for Winning Your
CFIDS is challenging enough without the
additional stress of fighting a disability insurance company. Many workers are
insured under policies that are supposed to provide financial protection in the
event that they cannot work full-time in their current occupations. But a great
number of these claims are denied — not because the claimant is not disabled,
but because either the claimant or her doctor made a preventable error when
dealing with the insurance company.
Here are six common mistakes, and tips on how to avoid
Not knowing what is in your doctors’ records before you
make your claim
Insurance companies will only pay benefits if they are
convinced that your medical records contain adequate, objective proof of
disability. As soon as you file your claim, these companies will request records
from your doctors (and from any doctors referenced in those records) and
carefully scrutinize them. You must get these records in your hands before you
file your claim. Review them yourself. Are they accurate?
Are they complete? Has the doctor recorded all of your
In one case, an insurance company denied benefits because
included in the records sent by the doctor were the records of another person!
Those records said “all is well” and the insurance company relied on those
records. The claimant never knew that the files her doctor sent had someone
else’s records in them because she didn’t get her doctor’s records first. It was
only after she hired a lawyer and sued the insurance company that she discovered
Not understanding your policy before you file your
Insurance polices are notoriously hard to understand. You
should obtain and review your policy before you file your claim. If your policy
is an employer-sponsored policy, you should obtain both the Summary Plan
Description (SPD) and the insurance policy itself before you file your claim.
The Employee Retirement Income Security Act (ERISA) requires that these
documents be made available to you upon written request to the employer’s plan
administrator. If you have a private policy and cannot locate it, call your
agent. You can obtain a replacement policy (usually for a small fee) from your
insurance company. Whether you have an employer-sponsored plan or a private
policy, make sure you obtain and read all amendments and endorsements to the
policy. It’s also an excellent idea to review the plan with a qualified attorney
prior to filing, to avoid costly mistakes.
Trusting the advice of the H.R. department
Oftentimes employees have been taught to take all questions
about benefits, including long-term disability benefits, to the Human Resources
department. This well-meaning advice can be fatal to your claim if the advice
you get is wrong. We don’t suggest that your employer would deliberately mislead
you, but our experience tells us that (1) most human resources personnel are not
legally trained in the interpretation of insurance policies; and (2) human
resources staffers generally have no pull whatsoever with the insurance company.
Again — unless the employer is actually funding the monthly
benefits (and this is a rare occasion) — it is the insurance company that is
protecting its own assets. Our experience, based upon reviewing many insurance
claim files, is that no amount of pleading by your employer will influence an
insurance company that wants to deny benefits to you. You need to take personal
responsibility for your own claim.
Using only insurance company forms to document your
When you make a claim for benefits, the insurance company will
send claim forms for you and your physician to complete. Typically, the
physician forms will have questions such as: “How much can this person lift? How
long can he sit? Can she walk long distances?” These questions are irrelevant to
CFIDS claims. The doctor will dutifully
answer the questions the insurance company asks, but later the insurance company
will say that those answers just weren’t enough information.
You should sit down with your doctor (after having fully
reviewed your own records), explain the terms of your policy and get your doctor
to set out fully in a report why your sickness or illness prevents you from
performing the substantial and material duties of your occupation. The doctor
may charge you for this report. Pay the charges! It is far better to have a
well-documented claim from the beginning than to have to go back, after you have
been denied benefits, and justify your claim. Also, if you have been denied
benefits and are appealing your claim, you and your doctor will have a limited
time (as defined in your policy) within which to submit additional reports. Why
be under time pressure when all of this work can be done before you ever submit
Using the insurance company’s lawyers to file for Social
If the disability insurance company pays you long-term
benefits, you will usually be required to file for Social Security benefits. If
you win your case, you typically will be required to reimburse the insurance
company, and further benefits will be reduced by the amount of the Social
Security payment. If your dependents receive Social Security benefits because of
your disability, your payments will also be reduced.
Many insurance companies will offer you the services of their
lawyers (or an affiliated law firm) to file for and pursue your Social Security
benefits. Don’t use them. We have seen too many instances where these lawyers
have steered the claim towards a disability that is favorable towards the
insurance company — for example, a mental condition that limits the insurance
company’s payments to two years.
We have also seen situations where an insurance company lawyer
who is representing a claimant in Social Security proceedings quits the case
because the disability insurance company decides to terminate your benefits
Not hiring a lawyer experienced in disability insurance
A new client told me recently that “you guys are hard to
find.” I asked him what he meant and he told me that he had searched for a long
time before he found an attorney who specializes in disability income insurance
litigation. Unfortunately, there are just not many of us out there.
Litigation of a long-term disability insurance claim is
different from litigation of an automobile accident claim. It is different from
many other contract claims. The world of insurance dispute litigation has its
own body of case law, history, procedure and terminology. Your attorney should
know, before the case begins, what you will need to prove in order to win your
case. You should look for an attorney experienced in disability litigation.
Ben Glass is an attorney in Fairfax, Va., who has
represented individuals against insurance companies for 20 years. This article
is excerpted from his booklet, “14 Ways to Guarantee that Your Long Term
Disability Claim is Denied, and You Lose in Court (avoid them and you may have a
chance at winning).” The complete booklet, which contains examples and documents
from actual cases, is available for free by calling 800-561-1670, ext.