IDI Policy Claims and Appeals
Individual disability income policies are highly nuanced and applications for benefits under these policies must be carefully prepared in order for insureds to successfully invoke coverage. As an initial matter, you, the insured, must reread your policies carefully for all application requirements, specifically to watch for deadlines for claims, and exclusions. Based on our disability attorneys’ experience assisting insureds under individual disability policies with applications and appeals, many contested claims can be avoided if the following suggestions are followed:
First, the insured should provide a description of his job to his treating/attending physician (AP). This description should be detailed and include specific duties that are substantial and material to his occupation. Then the AP complete the Attending Physician Statement (APS) with specific comments on how the insured’s limitations prevent him from performing those duties as of the date the insured alleges disability, particularly noting how he is precluded from performing such duties on a sustained basis (8 hours a day, 5 days a week).
Second, provide an addendum to the APS form to the insurer. In addition to having the AP complete the Restrictions and Limitations section of the APS, also have him draft an addendum report. The addendum should be a narrative letter, describing in detail the functional restrictions and limitations caused by the insured’s medical condition. The AP should state that his opinion is based on clinical examinations and observations, diagnostic testing, and any objective labs, x-rays, tests, MRIs etc. The doctor should also provide a statement noting his opinion is supported by treating other patients with the same condition. He should state how long he has treated patients with this condition, and that they have had similar symptoms, complaints and limitations as the insured, due to that same diagnosis. Thus, he has experience and knowledge substantiating his opinion.
Third, submit medical evidence supporting the AP’s opinion. Include the medical evidence that he relies on including his treatment notes, diagnostic tests and reports, and any objective labs, x-rays, tests, MRIs, etc.
Fourth, encourage the AP to be honest and thoughtful with these responses, but not to exaggerate. Exaggeration will only hurt the insured’s claim, because it may appear that the doctor will say anything to support disability and he is advocating for the insured instead of treating the insured and merely reporting his findings. This will damage the credibility of your AP’s opinion.
Fifth, provide statements from supervisors and colleagues describing the difficulties the insured endured while working with his condition to the insurer if the condition was progressive. These statements should note any special conditions the insured worked under, any accommodations that were made to allow the insured to continue working with the condition, how often the insured was late or absent due to the condition, whether the insured took FMLA leave, etc (a copy of an attendance record would be appropriate to include as well).
Sixth, collect and submit narratives from family and friends to the insurer. They should state their personal observations and include “before and after” disability observations. They should list things that the insured used to do that the insured can no longer do due to the condition and they should describe changes in the insured’s daily activities.
Seventh, submit all other relevant medical records to the insurer. Provide the insurer medical records not included in the insured’s AP’s medical file. These may include hospital discharge reports, physical therapy treatment notes, etc.
Eighth, include pictures or video evidence demonstrating the insured’s disability and accommodations made in the insured’s home with the application for benefits to the insurer.
Ninth, if the policy has a 2-year limitation (this could be on mental-nervous or musculoskeletal disorders), be sure that the AP states what the insured’s primary diagnosis is versus an Axis II, III or IV diagnosis. While it is a well-known fact that individuals suffering from chronic conditions often experience depression (especially individuals suffering from fibromyalgia, chronic fatigue, lime disease, and chronic migraine headaches), the insured or his AP should not note it if it is not the primary diagnosis.
And tenth, do not communicate over the phone with the claim representative that the insurer assigns to the claim and inform the insured’s physician[s] of the same. Send an initial letter with the application to the claim representative stating, “in order to avoid miscommunication, I ask that all communications to myself or to my physician[s] be in writing and sent to via certified mail.” Also review the HIPPA authorization and insert a note by the authorization to contact physicians in writing only.
This list of tips is certainly not exhaustive but providing the insurer with salient medical, vocational and sometimes financial information will placate the insurer’s concerns that the insured has satisfied all the preconditions of coverage.