In an ideal world, you’d receive a favorable decision and your first benefit check shortly after your policy’s elimination period is satisfied. Unfortunately, even wholly legitimate claims get scrutinized, questioned, delayed, and in some cases, denied. Below are a few common reasons benefit payments are delayed, particularly at the outset of a claim.
Improperly Completed/Partially Completed Forms
If your initial claim forms are missing information, unreadable, or incomplete, your insurer will likely issue additional forms for completion or use the missing information as an excuse to delay processing the claim. This applies to both the forms that you are required to complete and sign and the forms the insurer gives you to give to your doctor to fill out, so it is important to follow up with your doctor and make sure that all of the necessary forms are completed and returned in a timely fashion. If you do not carefully document your claim, and you do not promptly respond to requests for follow-up information, most insurers will delay making a claim decision until you provide them with the requested information.
Pending Requests for Information
At the outset of your claim, your insurer will require you to sign an authorization that allows them to request a wide range of information from a wide range of sources, including your doctors and employer. Oftentimes, the insurer will request information from these other sources (without telling you) and then will delay making a decision on your claim if any of these requests remain pending.
This means that even if you provide the insurance company with everything they requested from you, there may be other information that the company is waiting that is holding up the claims decision. Consequently, it’s important to ask the insurance company to find out if there are any pending requests, adn then follow up with your doctors, employers, etc. as needed to ensure that the information is provided.
It’s also important to keep tabs on the pending requests, to determine whether the scope of the insurer’s investigation is appropriate. An experienced disability attorney can advise you on whether a particular request for information is warranted under the circumstances of your particular claim.
Failure to Schedule Medical Examinations/Interviews
When you file a disability claim, insurers will almost always require that you participate in a detailed interview and/or undergo an independent medical examination (IME). While the stated point of these requests is to confirm or verify your disability, they can often be an attempt by your insurer to discredit your own doctor or medical records and generate fodder to deny your claim. Depending on the nature of your condition, your insurer might also request other types of interviews or exams—such as a functional capacity evaluation (FCE) or neuropsychological evaluation.
Some claimants (mistakenly) believe that if they keep putting off these exams, then they’ll be able to avoid the exams. However, most disability policies contain a provision that expressly requires the policyholder to submit to exams, and states that failure to do so is grounds for denying a claim or terminating benefits. So if you put off these exams, it’s only going to delay the company’s claim decision, and possibly result in a claim denial. However, keep in mind that going into a medical examination, IME, or interview unprepared can be just as bad for your claim, so it’s very important to prepare beforehand. Once again, an experienced disability attorney can advise you regarding the proper scope of an interview or IME, and can also be present for the interview or IME, if desired.
Disability insurance companies are constantly searching for new ways to expand the power and control they have over their policyholders through the use of restrictive policy provisions. In previous posts we’ve discussed how disability insurers are expanding their control over their policyholders’ medical treatment by implementing more stringent care provisions. However, care provisions are not the only avenue for disability insurers to exert a greater degree of influence in the claims process. Over the years, insurers have also expanded the scope of their authority under examination provisions.
The most basic examination provisions simply notify the policyholder that he or she may be examined by the insurer’s doctor or interviewed by a representative of the insurer, like this policy from Northwestern Mutual:
- Medical Examination. The Company may have the Insured examined by a health care practitioner.
- Personal Interview. The Company may conduct a personal interview of the Insured.
- Financial Examination. The Company may have the financial records of the Insured or the Owner examined.
Taken alone, this does not seem to onerous. However, you need to watch out for additional requirements buried at the end of the provision:
Any examination or interview will be performed:
- At the Company’s expense;
- By a health care practitioner, interviewer or financial examiner of the Company’s choice; and
- As often as is reasonably necessary in connection with a claim.
The final sentence of this provision leaves the open the possibility of multiple interviews throughout the claim, and may be overlooked by a claimant who does not carefully review his or her policy.
Other provisions, like this medical examination provision from a Standard Insurance Company individual disability insurance policy, expressly condition the payment of benefits on your cooperation with the exam:
MEDICAL EXAM – We can have Physicians or vocational specialists examine You, at Our expense, as often as reasonably necessary while You claim to be Disabled. Any such examination will be conducted by one or more Physicians or vocational specialists We choose. We may defer or suspend payment of benefits if you fail to attend an examination or fail to cooperate with the person conducting the examination. Benefits may be resumed, provided that the required examination occurs within a reasonable time and benefits are otherwise payable.
In newer policies the language used by the disability insurance companies has become ever more burdensome. For instance, some modern provisions for examinations and interviews create far more specific duties for the policyholder and condition the payment of benefits on the claimant’s satisfaction of these duties. Take this Guardian policy, for example, which outlines the policyholder’s duties and obligations to comply with examinations and interviews in very specific language:
We have the right to have You examined at Our expense and as often as We may reasonably require to determine Your eligibility for benefits under the Policy as part of Proof of Loss. We reserve the right to select the examiner. The examiner will be a specialist appropriate to the assessment of Your claim.
The examinations may include but are not limited to medical examinations, functional capacity examinations, psychiatric examinations, vocational evaluations, rehabilitation evaluations, and occupational analyses. Such examinations may include any related tests that are reasonably necessary to the performance of the examination. We will pay for the examination. We may deny or suspend benefits under the Policy if You fail to attend an examination or fail to cooperate with the examiner.
You must meet with Our representative for a personal interview or review of records at such time and place, and as frequently as We reasonably require. Upon Our request, You must provide appropriate documentation.
Examination provisions containing language this specific and this restrictive significantly limit your rights. The most significant change in the evolution of the examination provision is the number of obligations upon which your benefits are conditioned. This policy language allows disability insurers to use your benefits as leverage to compel your compliance with medical exams, interviews, and a litany of other examinations.
Review your disability insurance policy, and particularly your examination provisions in the “Claims” section, to determine what your rights, duties, and obligations are under your policy. Unfortunately, if your policy requires to participate in examinations, a refusal will likely lead to a denial of benefits. However, you do not have to attend alone. No matter how restrictive the language in your disability insurance policy, you always have the right to have an attorney present for any examination or interview. If you have any questions about your duties or obligations under your policy, contact an experienced disability insurance attorney.
We are expanding our list of insurance company profiles that specifically market to dentists and doctors to include Principal Life.
Principal Life (also known as “Principal Financial Group”) was founded in 1879. Initially, Principal Life operated primarily as an insurance company. Principal Life is now a member of the Fortune 500, and offers several additional services, such as retirement and asset management. Principal has most recently realized a growth in net income from $1.112 billion in June of 2014 to $1.290 billion in June of 2015.
Company: Principal Financial Group or The Principal.
Location: Des Moines, Iowa.
Associated Entities: Principal Financial Services, Inc.; Principal Life Insurance Company; Principal Real Estate Investors, LLC; Spectrum Asset Management, Inc.; Post Advisory Group, LLC; Columbus Circle Investors; Edge Management, Inc.; Morley Financial Services Inc.; Finisterre Capital, LLP.
Assets: $530.3 billion.
Notable Policy Features:
Principal Life sells polices that define “disability” as “own occupation”, which means that you are considered totally disabled if you are unable to perform the duties of your occupation. While this may seem like the right policy for a medical professional, you should be aware of a couple caveats. Coverage under a Principal Life policy is, in part, based upon a key definition that is usually referred to as your “occupation period.” Essentially, your “occupation period” is the time frame during which the “own occupation” definition of totally disabled applied. Once the “occupation period” has expired, Principal Life will only pay you benefits if you are unable to work in any occupation that you are reasonably suited to work in, based on your education, training, and experience.
The length of your “occupation period” can range from a base of 2 years after your disability to a period of 5 years, until age 65, until age 67, or until age 70, depending on your “occupation class.” Oftentimes, the policy provisions regarding “occupation periods” can be convoluted and difficult to decipher. If you unsure about the length of your “occupation period” under the terms of the policy, an experienced disability insurance attorney can help you understand the applicable policy language.
Claims Management Approach:
In comparison with other insurance companies, Principal Life generally conducts more in-person field interviews with claimants. Principal Life will not only conduct a field interview when you initially file your claim, but will also likely conduct several additional follow up interviews throughout the claims process.
Most insurance companies require you to fill out generic questionnaires that ask for information about the nature of your disability, among other things. Because Principal Life handles a lot of disability claims by physicians, it has created a particular “Medical Professional Occupation and Financial Questionnaire” that is more comprehensive than a generic questionnaire, and is specifically tailored towards collecting information from medical professionals. The questionnaire is quite extensive, and asks about a wide variety of information, from your ownership interest in your practice, to whether your practice participates in a health care network, to the credentials of the medical professional owners and associate professionals you work with, to whether you receive any reimbursements from prescriptions. If you are unsure about the content or scope of any questionnaire you receive, an experienced disability insurance attorney can help answer any questions you may have.
In the last few posts, we’ve looked at a few of the most common disability insurance companies for doctors. See our profiles of MassMutual, MetLife, and Northwestern Mutual. Guardian is another disability insurer that specifically markets its policies to physicians and dentists.
Guardian has been around for over 150 years and is one of the largest individual disability income insurance providers in the United States. Guardian’s business model emphasizes the need for continuous growth, and Guardian reports that it has paid out dividends to its owners every year since 1868. To reach its goal of uninterrupted growth and live up to its owners’ expectations that it will pay out dividends each year, Guardian must not only maintain its past levels of profitability, but also come up with new ways to be more profitable. Obviously, from Guardians’ perspective, denying high paying claims submitted by physicians and dentists is an attractive method of increasing its profits.
Company: The Guardian Life Insurance Company of America.
Location: New York, New York.
Associated Entities: The Guardian Insurance & Annuity Company, Inc.; Berkshire Life Insurance Company of America; Guardian Investor Services, LLC; Park Avenue Securities LLC; RS Investment Management Co. LLC; Reed Group, Ltd.
Assets: $84.1 billion in 2013.
Notable Policy Features: Guardian policies oftentimes attach a “Residual Disability Rider” to their policies. This rider could impact you in significant ways if you are partially disabled and considering part-time work. For instance, the residual disability rider to your policy might contain the following provisions:
“Income. Income means your gross earned income, less business expenses, but before any other deductions. It includes salaries, wages, fees, commissions, bonuses, business profits or other payments for your personal services.”
“Prior Income. Prior income means your average monthly income for the tax year with the highest earning in the three years just prior to the date on which you became disabled.”
“Current Income. Current income means all income which you receive on a cash basis in each month while you are residually disabled.”
“Loss of Income. Loss of income means the difference between your prior income and your current income.”
“Residual Indemnity. Residual indemnity = (loss of income/prior income) x monthly indemnity.”
“Termination of Residual Indemnity. Residual indemnity will stop when the first of the following events occurs:
- you become totally disabled; or
- the benefit period ends; or
- your loss of income is less than 20% of prior income . . . .”
When read together, these provisions essentially mean that if you are partially disabled and working in another occupation, Guardian includes the additional income earned in that occupation when determining your current monthly income. This is important because you could lose your residual disability benefits if, after adding in your additional income, your loss of income amounts to less than 20% of your prior income. If you have this residual rider in your policy, you should be aware that accepting part time work could jeopardize your ability to collect residual disability benefits.
Read more about residual disability benefits.
Claims Management Approach: Like many of the other insurance companies we have profiled, Guardian frequently conducts in-home field interviews, in an effort to catch you off guard and observe you in a state of activity that may not accurately reflect the severity of your condition. In-home field interviews also allow Guardian to collect personal information, such as your daily routine, hobbies and interests, names of friends and family, and work hours, so that its private investigators can more easily conduct surveillance of you.
If your claim involves a psychological disability, Guardian will likely require you to submit proof that you are being treated by a PhD level therapist, even if you have been working with a non-PhD level therapist for a significant period of time. Consequently, if you have a Guardian policy and are in need of therapy, you might want to consider consulting with a PhD level therapist from the start.
A final tactic frequently used by Guardian is the peer-to-peer call, which consists of Guardian directly contacting your treatment providers over the phone without your consent. This tactic is similar to the in-home field interview in the sense that it is an attempt to catch your treating physicians off-guard by ambushing them with detailed questions about your disability. Since these discussions take place over the phone, your treating physicians will likely not have an opportunity to provide well thought out, thorough answers, and there will likely be little, if any, documentation of the call. Although this tactic is alarming, it is easily countered. As we explained in a previous post, peer-to-peer calls can be preempted in most cases if you have your attorney notify the insurance company that all communications with your treatment providers must be coordinated through your attorney’s office.
These profiles are based on our opinions and experience. Additional source(s): Guardian’s 2013 Annual Report; Guardian Fact Sheet 2013; guardianlife.com.
In this series, we’re taking a look at some of the most popular disability insurance companies for doctors. See our profiles of MassMutual and MetLife. Northwestern Mutual is another disability insurer that specifically markets its policies to physicians and dentists.
In 2014, the company insured 476,000 people through 727,000 individual disability policies. Northwestern Mutual prides itself on paying more dividends that its competitors. In order to do that, of course, it must maintain consistently high profit levels.
Company: Northwestern Mutual Life Insurance Company.
Location: Milwaukee, Wisconsin.
Associated Entities: Northwestern Long Term Care Insurance Co., Northwestern Mutual Investment Services, LLC, Northwestern Mutual Wealth Management Co., The Frank Russell Co.
Assets: $217.1 billion in 2014.
Notable Policy Features: Northwestern Mutual sells policies with an “own occupation” definition of total disability. However, these policies are often only truly “own occupation” for a limited amount of time, after which they become any occupation policies (only providing benefits if you are unable to work in any job) or “no work” own occupation policies (only providing benefits if you are unable to perform your job duties and are not working in another job).
For instance, a Northwestern Mutual policy might include the following definition:
Total Disability. Until the end of the Initial Period [defined elsewhere as 60 months of benefits], the Insured is totally disabled when is unable to perform the principal duties of his occupation. After the Initial Period [i.e., 60 months], the Insured is totally disabled when he is unable to perform the principal duties of his occupation and is not gainfully employed in any occupation.
In order to make sure a Northwestern Mutual disability insurance policy keeps the own occupation definition for as long as you hold the policy, you may need to purchase an additional benefit rider.
Read more about Northwestern Mutual’s interpretation of its own occupation policies.
Claims Management Approach: Some of the claims strategies that Northwestern Mutual is known to use include conducting in-home field interviews on top of third-party surveillance, hiring its own medical consultants to review claimants’ records and opine on whether or not they are disabled, and demanding that claimants (especially those with mental conditions) undergo “independent” medical examinations (IMEs) with providers of Northwestern Mutual’s choosing.
These profiles are based on our opinions and experience. Additional source(s): Northwestern Mutual’s 2013 Annual Report; Northwestern Mutual Fact Sheet 2014; Forbes.com.
We’ve discussed why an insurer might want to schedule a field interview and what to expect before and during the interview itself. Now we review what claimants can expect can expect after the interview ends. Again, the process is usually different depending on whether not a disability insurance attorney is involved.
After the Field Interview
After your interview ends, the field representative will leave to do some additional reconnaissance. Without telling you, the representative may drive to your office to talk to people on your staff. He or she will see what the office looks like, if it’s busy, and whether your name is still listed on the door. If you have an attorney, the attorney will have discussed this with you ahead of time, and together you will have taken steps to make sure the representative doesn’t bother your staff or catch them off guard.
Some days after the field interview, the representative will send you a copy of his or her report, which purports to summarize your conversation. The report will ordinarily be 8 to 10 pages or more. He or she will ask you to review the report, make any changes you see fit, and return it. The representative will advise that if you don’t make any changes by a certain date, he or she will assume that everything in the report is accurate.
For claimants with legal representation, the report will be sent to your attorney’s office. Your attorney will review the report to make sure that it accurately reflects the facts of your claim. He or she should be able to correct any seemingly harmless statements that a claims adjuster may take out of context to support denying or terminating your claim. If any important information is missing, your attorney will make sure to include it along with the report.
Meanwhile, the field representative will usually send a separate report to the insurance company. This second report will have the representative’s personal observations about you, their conversations with your staff, and any other information he or she was able to gather about your outside of the interview. You will not be provided with a copy of this report unless you’re able to obtain the claim file after your claim has been terminated or denied. If you have an attorney, this second report will be much more limited, as the representative will not have had the opportunity to visit your home or to pry into irrelevant or confidential information. If your claim is denied or terminated, your attorney will obtain and review this report for any inaccuracies or misstatements.
A field interview can be intimidating, but knowing why the interview is being conducted and what to expect during the process can make you better prepared to handle it in a way that doesn’t prejudice your claim. If you have questions or concerns about a field visit, contact a disability insurance lawyer right away.
Our last post discussed why an insurance company might want to conduct a field visit or field interview. Now that you know what the insurer is trying to accomplish, we’ll discuss what exactly to expect before the interview, during the interview, and afterwards. As with many aspects of the claims process, the field interview will be different depending on whether or not you have a disability insurance attorney involved. First, what to expect before and during the interview:
Setting Up the Field Interview
Initially, the field representative will call or e-mail you personally to set up a time to meet. He or she will ask to come to your home, or sometimes your office (particularly if you have been practicing as a dentist or physician), and talk one-on-one. If you’re being represented by a disability insurance lawyer, the field representative will call or write a letter to the lawyer’s office to request a field interview. Your attorney will evaluate whether the in-person interview is necessary and appropriate under the terms of your policy and your particular claim situation. If so, your attorney will likely ask the field interviewer to meet at the attorney’s office, rather than in your home or office. Your attorney, and sometimes an assistant as well, will attend the interview. The attorney and/or his or her assistant will take careful notes of the entire conversation.
During the Field Interview
When the representative arrives, he or she may ask to take your photograph. The representative may also ask to audio-record your conversation. If an attorney is present, the representative will usually refrain from asking to take a photograph or audio-record the conversation, knowing that your legal counsel will likely determine it unnecessary and/or inappropriate.
The field representative will sit down and talk with you for an hour or more. He or she will have an extensive list of questions to ask you, most of which your claims analyst will have specifically requested the representative address. For those with legal representation, your attorney will have prepared you for each of the questions the representative will ask, so you’ll be ready to give accurate and well-considered answers.
During your conversation, the representative will be very warm and friendly. The representative will normally try to establish a rapport so that you’ll relax and talk openly. He or she will try to get you to talk without thinking, encourage you to go into unnecessary detail, and may ask personal questions that a claims adjuster would normally avoid.
The representative often acts somewhat more reserved when an attorney is present. Field representatives know that if they ask any questions that are irrelevant, seek confidential information, or are otherwise inappropriate, your attorney will intervene and let you and the representative know that you don’t need to answer the question.
While you’re talking, the field interviewer will take copious notes. These notes will include the interviewer’s own observations about your appearance, how well you move, how long you were able to sit or stand, what your house looks like (if in your home), and whether you seem nervous or not. If your attorney attends, the representative will know that his or her notes will be compared against the attorney’s, so he or she will be especially careful to document the circumstances accurately.
In our next post, we’ll talk about what happens after the field interview ends.
At some point after you’ve filed a disability insurance claim, your carrier may contact you to arrange a “field interview.” Also called a “field visit,” a field interview is when a disability insurer hires a representative to come meet with you face-to-face to talk about your benefit claim. Most times, the company will ask that you meet the field representative at your own home or office.
Your claims analyst will probably tell you that the field interview is just a way to get to know you better, or to help the company gain a better understanding of your claim. What the claims analyst won’t tell you are the real reasons why insurance companies put so much time and effort into planning in-person field interviews, such as:
- To take your picture so that a private investigator will recognize you during surveillance.
- To find out what your house and/or office looks like to further aid in surveillance.
- To look inside your house and see if you’ve been doing a lot of housework, paperwork, cooking for yourself, etc., all of which (according to the insurance company) can mean you’re able to work in your own occupation.
- To see if you look like you’re in pain, if you can sit down for a long period of time, or if you can walk without any gait abnormalities.
- To see if you look like you might have current monthly income from sources other than your occupation (i.e., if you have a nice car, a big house, a boat, etc.).
- To drop in and try to interview your spouse, former business partners, office manager, or neighbors.
- To try and get you to relax and open up, or to catch you off guard so that you give information the company can use against you.
In our next post, we’ll discuss what you can expect during the field interview itself.