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Disability Insurance Claims Ė An Inside View (Part 4)

By Gerry Katz, MSPA, RHU, ALHC, DABFE, FACFE

 

In this final part of our view of the disability insurance arena, I first want to briefly walk through a "typical" claim. If you follow this claim from left to right and in that order through each level, you get a general impression of this process.

From the representative picture view of this sample claim, the insured usually calls the insurance carrier for the disability claim form. This form is actually a small package including the insuredís portion, a portion for the employer (if not self-employed) and a third portion for the attending physician to complete. Please remember that this merely initiates the claim.

A claim file is opened at the home office of the company (or at a third-party vendor) and the claims representative will then either call or write to the disabled insured for additional information. This may include several years of personal and business tax returns, a clarification about the insuredís specific job description and occupation and possibly, additional medical information.

Medical information will be sent to the medical department of the company for review by a physician and possibly, a specialist who may or may not be a full-time employee of the company. The claims representative will send all the financial information to an in-house CPA or accountant for review and analysis, especially if the claim involves "residual" disability benefits

The medical and financial analysis conclusions will be returned to the claims representative with any notes of concern and possibly, the need for additional information. The claims representative will then contact the insured and at this point, there may be a request for a phone or face-to-face interview to further clarify information developed during these investigative stages. Depending upon the type of claim involved (total or residual disability) there may be additional forms to complete. These are often related to specific occupations such as a Trial Attorney, Surgeon or Dentist. They ask for a significant breakdown of the occupational duties and can include several months of daily routine and for medical or dental billing codes.

Many mergers have taken place in the disability insurance business. This has in my opinion created significant changes within our industry that have caused many companies to downsize, retire some of their most skilled employees and within the claims arena, have created havoc!

Many disability claims are processed and paid on a timely basis. There are however, a growing number of long delays between initial submission of a claim

and its ultimate conclusion. Sophisticated investigative tools that I reviewed in Part 3 are used in a growing number of these claims, providing insurance carriers with a great deal of sometimes "myopic" information.

Having worked in the disability insurance industry for more than 35 years and working within the claims area for the past several years, I have come to the following conclusions. Many claims are delayed with additional layers of investigation, rotating claims personnel to other areas within the insurance company and others are simply handled badly!

Disabled policyholders do not understand the communication process involved in claiming benefits. They donít really know the "language" of disability claims and they are easily placed in a defensive position. While companies must pay only legitimate claims and therefore, have and use the tools necessary to adequately investigate all claims, I believe the cards are stacked against most of your clients who are disabled and apply for disability insurance benefits.

What can your clients to do gain a level playing field when they apply for disability insurance benefits? They should first, seek advice from an experienced disability claim consultant. Someone who understands policy terminology and the disability claim process. They must understand how their specific disability "fits" into policy language and most important, how to communicate their pre and post disability condition. Your disabled client must be able to instruct his or her attending physician how to adequately describe the disabling condition and not merely detail symptoms and treatment.

A knowledgeable claimant has the best opportunity to collect disability benefits.

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