Three Grounds Used by Insurers to Justify Denial of a Professional Disability Insurance Claim

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

Throughout the 1970s and 1980s, the insurance industry aggressively marketed disability insurance to physicians, attorneys, executives, and other professionals.  This campaign to entice professionals to purchase long-term disability insurance policies was founded on promises of low monthly payments and high benefit levels commensurate with professional salaries. 

When the financial picture changed during the 1990s, changes in the economy compromised economic conditions for both insurance carriers and professional insurance claimants.  These changes motivated insurance companies to find new strategies for denying claims.  These shifts in the economy and the adaptations they spurned redefined the relationship of customer and service provider into adversaries.  Insurers began to view payouts on disability insurance policies to professionals as overly costly, motivating a search for grounds to rescind policy coverage and terminate payouts.

Because many professionals have their disability insurance claims denied, policyholders should obtain the guidance and representation of an experienced Disability Insurance Claims Lawyer early in the claims process.  While obtaining access to legal advice and representation is beneficial at all stages of insurance claims disputes, early intervention can mean that your interests are protected.

In this blog, we identify three of the most common grounds asserted for denial of a claims dispute involving disability insurance benefits for professionals. 

Lack of Cooperation with the Insurer Investigating the Claim: Once a disability insurance claim has been filed, the insurer will undertake an investigation to evaluate the claim and to assess whether the claimant qualifies for benefits.  During the investigation process, the insurance company will issue requests for information, extensive documentation regarding the disability, financial statements, and tax records.  While these requests cannot be used for the purpose of harassment or delay, failure to comply with reasonable requests will be used by the insurer to deny payment of the claim.

Not Disabled Based on Policy Definition: Insurers frequently deny claims by asserting that the policyholder does not meet the definition of “disabled” within the language of the insurance policy.  

Determination of No Disability Based on Change in Livelihood: This rationale for denial involves a common “gotcha” strategy used by disability insurance carriers.  Professionals typically are high achievers who often are especially motivated to make a living even after suffering a disabling injury or illness.  While this work ethic is admirable, the change to another occupation prior to filing a disability insurance claim can have a devastating impact on the individual’s right to receive benefits.  The occupation that is relevant in terms of a claimant’s disability is the job and duties performed during the year prior to the claim being filed.  If the claimant has shifted into another lower paying occupation prior to filing the claim, successful performance of the new less lucrative occupation can result in a denial because of the claimant’s ability to perform the tasks associated with the new job.

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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