Preparation Before Filing a Disability Insurance Claim
Before talking to any insurance company representative there are a number of things you should do.
First, do your best to analyze whether there are any arguments, pro or con, as to whether there is coverage for your situations. Take out your policy and the notes you kept from your discussions with the agent.
Re read this material carefully and talk to one of our attorney sponsors. A consultation is provided without charge.
Go to the “Definitions” page in your policy to see whether any of the words used in the sections pertaining to your claim are applicable.
Once you have determined that a particular loss is generally covered, the next thing to do is to find out whether there are any specific limitations that may be applicable to your situation. For example, some policies limit benefit durations for own occupation benefits, switching over to an any occupation requirement after that time. Other policies limit benefit durations for mental disabilities such as clinical depression.Be careful. If you have a mental or emotional disability there may also be a physical disability involved? This can be important because even policies that limit benefits in mental disability situations can not do so if there is a physical disability as well. This is called co-morbidity.
As you go through the process of doing your best to analyze the applicable coverage, remember the Rules of Construction discussed throughout this site. These are the rules (such as the one that any ambiguity must be construed in favor of the policyholder) that you can use to your advantage in the interpretation of your policy.
Second, calculate how much you are entitled to receive per month and for how long. Does your policy provide any “automatic’ benefit increases? “Optional” increases? Cost of living adjustments? Are there any waiting periods involved?
Locate the sections in you policy that talk about these things and take out a pencil and do the calculations. Again, if any of these sections are subject to more than one interpretation, the ambiguities must be interpreted in your favor.
Third, develop a strategy that will result in a fair and prompt resolution.
Anticipate everything you think the insurer will say about every aspect of your claim. Think about what your responses will be to any questions raised. It is important to avoid being blind-sided by unexpected issues.
Fourth, evaluate your Substantial and Material Duties.
Make a list of all of the substantial and material duties you normally must perform in your work. For example a house painter may have to climb ladders, carry heavy objects, drive a car, be able to hold a paint brush steady for long periods of time and so on. List all of the duties you perform.
Under most policies, and under the laws of most states, you are considered disabled if you are unable to perform your duties in the “same or similar manner” that you have performed them in the past. In other words you are not required to start using special equipment which allows you to do things differently (such as painting while seated in a specially designed chair to take pressure off your back).
Make sure that your list is thorough and accurate. The point is for you to understand exactly why you qualify for benefits under the specific terms of your policy.
Next: Filing a Claim