I’ve Been Paid Benefits For Years– Why is My Insurer Asking for More Information?
If your disability insurer has reassigned your claim or is asking for more information than usual, your claim may be targeted for termination.
If you’ve been on claim for a while, it is easy to become complacent and forget that your disability insurer is constantly evaluating whether you remain entitled to benefits. However, if you do not take care to meet your ongoing proof of loss requirements, you may find yourself facing a claim termination the next time your insurer conducts a review.
Why Do Insurers Reassign and Revisit Claims?
Sometimes, insurers will conduct broad reviews of all ongoing disability claims for financial reasons, to see if they can save any money by denying claims that they are currently paying.
On an individual basis, claims may also be singled out for heightened review after an insurer does online or in-person surveillance, or if an insurer requests medical records and the most recent records are limited or vague. In this second instance, an insurer may challenge whether the policyholder has met the policy’s ongoing care requirements. Another common example that draws heightened attention to a claim is changing jobs or job duties during a claim.
My Insurer Wants to Conduct a Medical Exam–Is this a Bad Sign?
One example of this is the case of Jue v. Unum. Dr. Jue, a dentist, was diagnosed with De Quervain’s Tenosynovitis. She became unable to work due to swelling and pain in her wrists and filed a claim under her Unum disability policy.
Unum approved the claim and, from 1998 to 2004, Dr. Jue submitted regular statements from herself and her physicians. These reports confirmed that her condition remained disabling. Then, from 2004-2011, Unum only required annual claimant statements and monthly income statements.
Dr. Jue changed doctors in 2012, and Unum began asking for physician statements from the new doctor. Then, in 2015, Dr. Jue took on some additional work responsibilities and was compensated for time spent on computer training. At the time, she was practicing as a dentist part-time, and did not want Unum to count the computer training income when calculating her partial disability benefits. This prompted Unum to reassign her claim to its “validation unit.”
In addition to evaluating the new source of income, Unum’s validation unit revisited the underlying medical condition. It referred her file to a physician to conduct a paper review and then required Dr. Jue undergo an independent medical examination. Unum’s doctor told her that she needed to have surgery, Dr. Jue refused, and Unum terminated her benefits, after paying her for over a decade.
This case highlights the importance of always having strong evidence to support your claim, even if your insurer is not asking for it as frequently. Most disability policies pay on a monthly basis. Consequently, insurers can (and do) conduct renewed investigations, often without warning. Even if your condition has not improved, you may still face a termination (or lawsuit) if you are not prepared to prove you qualify for ongoing benefits.
Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your claim has not received a full and fair review, an experienced disability insurance attorney can evaluate your claim and help you determine what options are available.
 Jue v. Unum Group, Case No. 19-CV-08299-WHO, 2021 WL 427640 (N.D. Cal. Feb. 8, 2021).