Tips for Claimants

• Read your individual disability policy, the long term disability plan and the Summary Plan Description. These documents may be difficult to understand, but do your best.
• Work with a friend, family member or professional who can assist you in gathering information and reviewing your paperwork.
• File your claim promptly. The insurance company has the right to know about your claim or potential claim in a timely manner. A failure to promptly submit a claim can result in the insurance company denying your benefits. Under the laws of certain states, you can be more easily excused if you do not file your initial claim or appeal promptly. The insurer will need to show that it was truly prejudiced by a “late” filing date.
• Gather your medical records and review the records for accuracy. Make sure that if there are errors or inconsistencies in those records that either you or your healthcare professional explains the errors or inconsistencies.
• Watch the insurance company’s or plan administrator’s deadlines. Check the plan and summary plan description. Sometimes the deadlines are not set forth in these documents.
• Do not assume your treating doctor’s opinion or a worker’s compensation rating is enough to establish disability: you must establish “restrictions” and “limitations” to support your claim that you are unable to work. “Restrictions” are activities that you should not do. “Limitations” are activities that you cannot do. A two-sentence letter from your treating doctor saying that you are disabled and cannot work is not enough. Keep in mind that plenty of individuals have been awarded Social Security Disability Income benefits from the Social Security Administration yet have been denied ERISA long term disability benefits. This may not make sense and is more often than not unfair, but this is a reality of the ERISA world.
• Be sure you submit vocational evidence demonstrating that you cannot do your job as it is described in the job description or the Dictionary of Occupational Titles (DOT), or O*NET. Although the DOT is out of date, many insurers rely on it, and sometimes courts do too. Remember, you need to link your medical condition to work impairment.
• Be careful when you contact the insurance company. Make your calls from home when you can. Insurers use caller ID. If you call from anywhere other than home, this raises insurers’ suspicions as to the legitimacy of your claim.
• Follow up all telephone communications with the insurer with a confirming letter. Never rely on oral communications. Try to interact with the insurer in writing as much as possible. The full-text of telephone conversations are not necessarily logged with 100% accuracy in the insurance company files.
• Be courteous to the insurance company employees. They have to listen to a lot of grief. There is NEVER a reason to be rude, even if the employee is rude. Don’t stoop to bad behavior. As the saying goes, “It’s easier to attract flies with honey than with vinegar.” Try to build a good working relationship with the insurance company case manager; but remain vigilant. Remember, you have one claim. The insurance adjuster handling your claim has hundreds.
• The insurance case manager may seem sympathetic; however, the case manager’s salary and bonus is paid by the insurer and not you. Watch what you say, because anything that remotely undermines your claim may be used against you. Well-trained insurance employees will do their best to gain your complete trust. Be on guard. Your obligation is to be truthful with the insurance company, and to respond to legitimate inquiries the insurer may have, but no more.
• When completing insurance company claim forms, be sure to include additional pages as necessary so you can fully respond to the insurance company’s inquiry. This is essential. Too often the insurance company forms do not provide sufficient space to fully and to completely answer question. Don’t be afraid to add pages. Don’t be shy about providing necessary detail so the insurer can understand why you cannot work. Illnesses and injuries affect each of us in distinct ways. For example, many people who have had heart attacks can return to work, but not all. Make sure the insurance company understands your individual situation.
• If the insurance company asks that you to describe a typical day, be careful. If you have a disease that has variable symptoms, such as chronic migraine headaches, fibromyalgia, or another illness where the symptoms change day to day, you need to respond appropriately. You need to tell the insurer about your “good days” and your “bad days.” If your so-called “good days” still would prevent you from working, be sure to express this clearly.
• Fill out claimant’s questionnaires carefully. Try to avoid answering questions with simple “Yes” or “No” or “Never” answers. If you said you cannot drive, you had better mean that. If what you really mean is that you cannot drive for more than 20 minutes, say so. If you say you cannot drive, and the insurer places you under surveillance, and finds that you drove 3 minutes to the pharmacy and 3 minutes back home, you might be accused of lying.
• If you just cannot truthfully answer a question, tell the insurance company and state, “I will supplement later.”
• If an insurance company schedules an “independent medical examination,” be aware of your surroundings days before and after the examination. Insurers often place claimants under surveillance during this time period.
• “Independent Medical Examiners” are rarely independent. Too many of these examiners are dependent on insurance companies for their livelihood. Make sure that the examiner has a full set of your medical records. Don’t rely on the insurance company to provide those. When it comes time for the exam, bring someone with you to take notes. Better yet, use a video recorder and make a record of the entire exam. Fair doctors will not mind you doing this. Do not make a secret video or audio recording. By recording the exam secretly, you may be violating criminal electronic surveillance laws.
• If you believe that you are under surveillance, talk to the person watching you. Legitimate private investigators will disclose who they are. You can always call the police. Do not hesitate in calling the police.
• If the insurance company wants to interview you in person, then try to meet at a location other than your home. If you want to tape record the interview, ask the insurance company representative in advance for permission. Do not secretly record the interview.
• Don’t post ANYTHING on the Internet that could be used against you. Insurance company employees will be running your name in Google. Information that may be innocuous or out of date that appears on a social networking site may be used against you. Claimants have been known to have lost benefits because they posted golf or bowling scores on websites. That goes for Facebook, MySpace, and other social networking pages, too. You should expect that an insurer will be searching in social networking sites to see if you are telling the insurer one thing and the world something contradictory. Information that you post may be taken out-of-context and used to justify denying benefits.
• If your claim is governed under ERISA, do not file suit until you have exhausted all your remedies. There are exceptions to this rule but you must fully understand the concept of “deemed exhaustion” in your jurisdiction.
• Don’t make the mistake of relying on the insurance company employee who tells you, “Just write on a piece of paper, I appeal.” Some insurance company employees have been known to make this recommendation. That is a guaranteed way to have your claim denied on appeal.
• Get competent assistance from needed professionals. When it comes to lawyers, you want to work with one who has substantial ERISA experience. ERISA is not an area of the law to learn on the fly.
• Ask yourself, if you need spinal surgery, would you consult with a spine surgeon or a general practice physician? To save some money, would you forego anesthesia? When your sole source of income may be at risk, or your health benefits, or other type of care, think very carefully before you elect to proceed on your own without the help of a professional versed in the appropriate discipline.

I am hoping that you find these tips useful. But don’t presume that a tip list is enough to get your benefits paid. ERISA is a particularly tricky and unforgiving area of the law.