INSURANCE DISABILITY CLAIMS
What is the Purpose of Insurance Disability Coverage?
A large number of Americans become disabled every year because of injury, sickness, or mental illness. Although a physical injury, sickness, or mental illness can be financially devastating, in some cases, the financial burden can be offset by having obtained insurance disability coverage. However, in order to be entitled to disability benefits, the coverage must have been obtained prior to the occurrence of the physical injury or the beginning of the sickness or mental illness.
It is very important that claimants understand that each insurance disability policy must be read in its entirety before a determination can be made regarding the amount and types of benefits available. While in come cases there are exceptions, many insurance policies providing benefits for the disabled usually follow the same guidelines.
The guidelines found in many policies are as follows:
- The claimant must have developed a sickness or spacermust have been injured after the effective date of the policy spacer(the date the policy started)
- The claimant must be disabled to the extent that he/she cannot perform spacerthe main duties of his/her occupation because of the injury or sickness
- The claimant must be under a physician’s care during the time spacerthat he/she is disabled
- The condition rendering the claimant disabled must extend spacerbeyond the applicable elimination period, which can usually range spacerfrom two weeks to 60 days
- The claimant must report the disability to the insurance carrier spacerwithin a prescribed period of time (usually 60 days) from spacerthe beginning of the disability; or, if for a particular reason spacerthe notice cannot be provided within the prescribed period of time, spacerthen the notice must be provided as soon as reasonably possible.
Filing a Successful Claim is a Complicated Matter
Filing a claim for benefits typically requires that you provide the insurance company a completed claim form, a copy of your medical records or a medical authorization, and a signed physician’s statement certifying in the physician’s medical opinion the date your disability began, the nature of your disability, and how long the disability may last.
The insurance company may also require that you resubmit a disability statement from your physician on a regular basis, possibly every 30 days.
The Entire Process Has Many Obstacles Which May Result in Denial of Your Claim
There are many factors which must be considered when making application for disability benefits, including whether the policyholder purchased the plan through an employer, or whether the policyholder purchased the plan privately. While the distinction between having a disability policy offered through an employer or having acquired it privately may seem insignificant, we assure you it is not.
Employer-based policies are usually governed by the Employee Retirement Income Security Act (ERISA), and usually have different criteria for appealing a denial of your claim. Private plans are usually governed by Texas law under basic contract principles and the Texas Insurance Code.
Even though a person’s physician may render him/her disabled within the meaning of the policy language, the physician hired by the insurance company may, and most likely will, have a different opinion. When the physicians disagree on the reasons for the disability, or disagree on whether a disability even exists, then it comes down to a battle of the medical experts.
An Experienced Attorney Can Help You
Understanding the terms within a policy can be difficult enough without having to manage medical care, obtaining medical records, getting a physician’s statement, and then handling your own claim. Additionally, if the proper procedures and documents are not done correctly the first time, there may not be a second time, as the damage done may be too severe to reverse.
If you have an active insurance disability policy and you believe you are entitled to compensation, then contact our office to speak with an experienced insurance disability attorney who has the judgment and wisdom to help you with your case. Call Joel A. Gordon & Associates for your free consultation with one of our lawyers.