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November 17, 2002 at 07:00 PM
How Agents Can Help Their Clients Get Disability Claims Paid
Its never been harder to get a disability claims payment.
Carriers and administrators seem to be scrutinizing claims with a higher degree of protection than the Secret Service provides to the president! But this gives you, as an agent or broker, a huge opportunity to learn the disability claims process and help clients secure the payouts theyre entitled to–and stand apart from competitors.
Today, many carriers have trouble differentiating a “legitimate” claim from a “gray area” claim. A hierarchy of individuals–including nurse practitioners, in-house medical personnel and accountants–is now involved in evaluating claims. Just one wrong answer or wrong word on a claim form or Attending Physician Statement could result in denial or termination.
Proper claim filing. Before your client submits claim forms or any other paper work to the insurer, you must know all the facts of the case. Start with a properly worded “Fact Finder” to uncover important details such as medical symptoms and clients duties.
In some cases, a dual occupation will apply whereby a person can continue working in his or her secondary profession but not in a main occupation. These individuals could be eligible for a partial (residual)–but not a total–disability claim.
You also need to understand the policy language, including the pre-existing condition clause and the incontestability clause. Just because your client has had this contract for two years doesnt mean he or she will be home free with a pre-existing condition. A contract with a fraudulent misstatement wording can render the incontestability clause open-ended, prompting the carrier to rescind or modify the policy–and deny benefits even after years of an in-force policy.
Moreover, if you dont know, for example, that partial disability may follow 60 to 90 days of total disability, your client could be devastatedand file an errors and omissions claim against you.
After gathering the facts and explaining the coverage to your client, you need to critique every line of each completed form to ensure accuracy and review any potentially ambiguous questions.
Carriers rarely offer a claimant the opportunity to adequately explain the events leading up to the disability nor the typical day or week before the disability–despite the long list of questions on these forms. Thats why you need to help clients prepare supplemental documents that clarify the key facts.
Physician communication essential. Most physicians cant distinguish a disability claim from a workers compensation or Social Security claim and receive little or no compensation from the insurer for completing forms that they consider an ongoing nuisance. This is especially true with surgeons, many of whom disdain the entire disability claims process.
Its up to you to explain how to communicate with the physician so your clients rights will not be unknowingly prejudiced. Explain that he or she must get the doctor to fully and accurately complete the Attending Physician Statement or questionnaire. A single mistake on the form–perhaps a doctors misinterpretation–could mean denial or termination and could cost your client millions of dollars.
One question commonly misunderstood by physicians is, “When is the patient expected to return to work?”–sometimes with terms such as “your occupation,” “any occupation,” “part-time” and “full-time.”
Many doctors, with limited time to complete the forms and little knowledge of policy language, often shoot from the hip and wind up submitting inaccurate information. For example, when asked to provide a date that the claimant will be back to work, the physician may erroneously insert the date that he or she will reassess your client.
