Obstacles to Obtaining Long-Term Disability Payments From an Insurer [Part I]

J.P. Gonzalez-Sirgo
Founder of J.P. Gonzalez-Sirgo, P.A.

The world of disability insurance benefits can seem like an alternate universe where nothing makes sense.  In a normal financial transaction, a consumer pays a fee for some specific service from a provider.  If the business selling the service satisfies its customers needs, the business grows based on word of mouth feedback and return business.  This is not how things work when the service provider is an insurance company.

While the disability insurer will be happy to accept your premiums, the carrier is gambling that it will never have to provide any service.  When the insurance company loses this bet and must actually process a claim, the insurer’s claim process often revolves around identifying a reason to provide nothing in return for the premiums that have been collected.  Since disability insurance benefits are purchased as a financial life raft for individuals who become unable to work.  This two-part blog post provides examples of the obstacles to obtaining long-term disability insurance benefits.

The Insurance Policy Is Written by the Insurer.  If you have ever tried to secure a copy of your disability insurance policy from deep in your boxes of “important papers” buried in the attic or from your employer to try and parse the language of the policy, you were probably shocked by the dense incomprehensible language.  After attempting to stay awake and concentrating on the first few paragraphs, you probably realized the policy is not very clear.  This is an astute observation because the disability insurance policy was written by a team of lawyers.  Thereafter, the policy was rewritten again and again over many years to limit the liability of the insurance company in increasingly subtle and underhanded ways.  Insurers know that policyholders almost never read their policy and that an insured is more likely to win the lottery than actually understand the policy.  Disability insurance carriers are counting on policyholders to “go it alone” and attempt to appeal a denial of benefits without the benefit of an experienced long term disability insurance lawyer familiar with the terminology and provisions commonly found in a disability insurance policy.

Insurers Provide Policyholders with “Generic” Letters of Denial.  When disability insurance carriers send a letter denying coverage, the reason provided for denial of the claim will so often be so vague and ambiguous, the policyholder cannot hope to know what is needed to resolve the claims dispute.  In the denial letter, the insurer will typically indicate that the insured failed to provide sufficient information or evidence that the insured is entitled to coverage under the policy.  The letter will then “helpfully” suggest that the insured submit further evidence, such as medical tests, doctor reports, supplemental reports and other documentation.  The point of this vague response is to lure policyholders into believing that the insurer just needs a little more information to approve the claim.  The false sense of security that approval of the claim is ever so close can dissuade the policyholder of the need to obtain legal assistance to appeal the denial.  If the insured appeals with some additional support and the claim again is denied, the final denial by the insurer will prevent the insured from introducing new evidence even if the matter is taken to court in most situations.  In other words, an insured needs legal representation during the administrative appeal to fully safeguard his or her probability for success in court.

Your Employer Has No Incentive to Help.  Many employees make the mistake of assuming that their employer is interested in ensuring they receive benefits under disability insurance policies because the employer provided the policy.  However, the policy was provided as an enticement to get you to take the job or continue working for the company.  The employer has no interest in helping you obtain benefits for not working.  When the number of employees receiving disability insurance benefits rises, the company may face higher premiums which cuts into profits.  Thus, an employer might impede your disability insurance claim by refusing to incur the expense of accommodations that can keep you working, such as less physically demanding tasks or adaptive equipment.  The company also might tell the disability insurance carrier of its “heroic efforts” to keep you working after you file your claim despite your unwillingness to work regardless of the accommodations made on your behalf. (Read Part 2)

You can reach Miami Insurance Claims Lawyer J.P. Gonzalez-Sirgo by dialing his direct number at (786) 272-5841, calling the main office at (305) 461-1095, or Toll Free at 1 (866) 71-CLAIM or email Attorney Gonzalez-Sirgo directly at [email protected].

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