Apr 30

6 Tips to Protect Your Disability Claim During A Field Interview

field investigatorOne insurance company tactic that regularly scares and intimidates many people is the field interview. These interviews can take many different styles, but they’re intended to look for and develop reasons to delay or deny your disability claim. Claimants often hopefully believe that allowing the field representative or investigator to come into their home and listen to how the illness or medical condition is affecting their daily lives will make the insurance company more sympathetic or understanding of their issues and more likely to pay the disability benefits. Unfortunately, these interviews seldom help claimants who may be naive, unprepared, or unfamiliar with basic interview techniques. And even then, interview reports can be skewed or spun to create “evidence” that supports a desired outcome and will be used as one of the reasons to deny a disability claim.

Our firm has seen many cases in which claimants have been burned by unfavorable interview reports, but fortunately there are ways that you can defend yourself and protect the disability benefits you deserve. Our experts have compiled a list of 6 tips we recommend to our clients to help prepare them for a field interview. Following these tips can help you understand the process and ensure that you’re prepared for some of the questions and tactics commonly used in disability claim interviews.

  1. Only answer the questions asked.  Listen carefully – and take your time! Investigators will ask questions that are designed to be complex and require long, open-ended answers. For example, they might ask “what do you do during the days?”  Don’t fall into this trap. Break the question down into sections or pieces. Professional investigators are trained and experienced to phrase questions and record answers that will allow them to take bits and pieces of your answers to create the desired narrative. It’s very important to give truthful, complete answers but don’t offer any information they don’t specifically request. Try to remain calm and composed during extended, even awkward, silences. Remember, the interviewer doesn’t actually care about your disability, they’re simply doing their job to investigate you and your claim for the insurance company.  In response to our example question, it’s impossible to answer – there’s practically no chance that you’d be able to list every single thing you do during every single day.  So, you could answer by citing an example of something you did before your disability that you can’t do now, or you could go through your medication and treatment regimen that you follow each day. Then most importantly, stop.  Be quiet and wait for the next question.
  2. Answer questions specifically and don’t speak in overgeneralities.  Our blog has mentioned this tip in earlier articles regarding IME’s and claim forms, but it’s an important point to reiterate here as well. For example, if you suffer from chronic back pain that prevents you from working at a desk for extended periods of time, don’t just say you are unable to sit. Be more specific. Go into the types of back pain, including the numeric ranges of pain that may come and go, that have been documented in your medical records that prevent you from not just sitting but also from working on a computer or being able to get up and down or adjust your position constantly. For example, an answer may be “Sometimes I can sit at a desk and type on a computer for 20 minutes before I have to gently stand up and move around, but on other days the pain is so severe, a 9 out of 10, that I can’t sit at all without excruciating, soul crushing pain.” Providing answers and details like these help reduce the wiggle room an investigator has to craft their report to fit the narrative they’re trying to create.
  3. Hold the interview in a public location rather than your house.  There’s nothing wrong with meeting an investigator in a convenient coffee shop or restaurant. If you let the investigator walk into your house, they will be constantly scanning for anything that can be construed against you or your claim. If you used to ski but your condition no longer allows you to, having ski gear visible in the garage will be brought up in the report and used to doubt your credibility – even if you haven’t picked them up in years. If the grass is cut and the bushes trimmed or even if the house is clean and tidy, this can be cited as evidence of activities inconsistent with your claimed restrictions and limitations. There’s nothing good that can come from giving an investigator more opportunities to come up with reasons to question and delay your claim.
  4. Don’t appear too comfortable.  You don’t want to appear too comfortable or relaxed during the interview. While you may want to fight through any pain and discomfort just to get the interview over with, investigators are trained to watch your body language and compare that with the restrictions and limitations as well as the symptoms of your medical conditions. It’s critical to remember that investigators aren’t just listening to your words. They’re studying you, watching your actions and body movements as well as how you answer their questions. If you stay seated for longer than you stated you’re able to, that will be used to impeach your restrictions and limitations, even if you’re taking measures to make it easier for you that wouldn’t be possible at work, such as sitting in a recliner with your feet up. It’s important to make your reported restrictions and limitations pretty obvious so that the investigator can’t overlook or ignore them.
  5. Have a friend or family member present at the interview.  There’s nothing wrong with having a second set of eyes and ears be with you at the interview. Having someone you trust with you during an interview is almost always helpful. While they cannot (and should not) interject themselves into the interview, a family member or friend can help provide emotional support, help make sure the interview from becoming a grueling process, as well as verify what was asked, said, and done during the interview process. They should keep detailed notes during the interview. Depending on the laws of your state, you may be able to record the interview. However, please understand that most investigators won’t agree to have their interviews recorded.
  6. Be wary of surveillance before and after your interview.  Another common tactic of insurance companies is to combine surveillance on days before and/or after your interview to try and record inconsistencies with your answers during the interview. Surveillance is an expensive claim investigative tool that can be used at anytime, but it’s more common around interviews. You should have notes to make sure you clearly state your limitations and restrictions to the investigator. Don’t try to overstate or oversell your disability to make your case sound better – that’s a sure way to endanger your entire claim. Investigators are well trained by insurance companies to notice any facts or seize any inconsistencies that don’t fit into the claim profile. Exaggerating your disability is unnecessary and harmful and can provide the insurance company with a reason to deny your claim. Make sure that none of your activities can be taken out of context. Even attempting to perform tasks that go against your doctor’s orders or are inconsistent with your condition, no matter how minor, can provide grounds to delay or deny your benefits. We’ve written several other articles on protecting yourself against surveillance here and here.

If you’re not prepared, interviews can be some of the most damaging pieces of evidence against your disability claim. Whenever interviews do occur in the claims process, investigators are trained to look for any inconsistencies or weaknesses in the claim. Although insurance companies often have the upper hand with their trained and experienced employees, you can and should refuse to accept any overly aggressive tactics. If you become uncomfortable or feel threatened, stop and reschedule the interview.  Following these tips can help lead to an easier claims process and prevent unnecessary delays in releasing your disability benefits.

If you have more concerns about an interview or are worried about one that has already been completed, we can help you defend your disability claim. Please fill out a free consultation request on the right-hand side of this page or call us toll-free at (855) 828-4100 to speak with one of our disability claim consultants and see how we can help you.

Apr 03

Advancing the Battle Against Cancer

An important breakthrough in the world of cancer treatment may help make great strides in helping slow and stop the spread of many different types of tumors. While new drugs or treatments are often mentioned that promise to slow or treat specific types of cancer, this new treatment may be different. Initial studies show that this new class of drug may be able to help across the spectrum of different types of cancer.

The research that led to this breakthrough began a decade ago when it was discovered that leukemia cells produce a protein called CD47 at a much higher rate than healthy cells. CD47 is a marker that prevents the immune system from destroying normal cells as they circulate throughout the body. Cancers take advantage of this hiding mechanism by utilizing CD47 to confuse the immune system into ignoring them, allowing tumors to spread and grow.

cd47Since then, researchers have focused on finding or creating a CD47-blocking antibody that would keep the cancer cells from producing this protein. And then, the immune system would be likely to “see” the cancer cells and attack them. In initial studies, results indicated that this antibody was able to block leukemia and lymphoma cells from producing the CD47 protein, allowing the immune system to fight back against these cancer cells that no longer had the protection to keep them hidden. Using this drug, researchers were able to create better outcomes in many cases of leukemia and lymphoma.

After realizing the capabilities of this CD47-blocking antibody, researchers expanded their studies to include other types of primary tumors outside the world of blood cancers. They made several frankly astonishing discoveries when expanding the study: the antibodies worked on every type of tumor they tested, and the amount of CD47 cancerous cells produce correlate with the survival odds for that type of cancer.

The first step was to determine whether blocking CD47 was beneficial. Researchers exposed different types of tumor cells to macrophages, a type of immune cell, and anti-CD47 molecules. When the researchers didn’t use the anti-CD47 drug, the macrophages were tricked into not seeing the cancerous cells. But when the anti-CD47 was present, the macrophages were aware of the cancerous cells and destroyed the cells of all tested tumor types.

The team of researchers then used tumors implanted into mice. When they treated the mice with anti-CD47, the tumors shrank and did not spread to the rest of the body. In one of the experiments, mice were given human bladder cancer tumors. After receiving the drug, only 1 out of 10 mice had lymph nodes with any signs of metastatic cancer. In addition, the tumors often shrank and allowed current treatments to be more effective. For example, colon cancer cells shrank on average to one-third of their original size. For breast cancer tumors, anti-CD47 eliminated all signs of the cancer cells, and the mice remained cancer-free more than 4 months after the treatment stopped.

Of note, blood cells also express CD47, which were also attacked by the immune cells.  However when mice were given the antibody, the study found that after stopping the anti-CD47 treatment, the decrease in blood cells was short-lived and the production of new blood cells increased to replenish those lost during the treatment.

While more research needs to be done and further testing is required before any treatments can be recommended or even developed, this is one of the most promising cancer treatment studies in a long time. Clinical studies are being fast-tracked for this very promising treatment. The potential for this new approach in the treatment (and even cure) of cancer is remarkable and may allow people who had few treatment options an increased chance to live long and full lives without many of the debilitating side effects that can be experienced. As this research develops and evolves, it’s exciting to envision the future that is possible.

If you or someone you love is battling cancer but is having issues with their disability insurance company or if you’re considering filing a disability claim due to cancer or the physical aftermath of cancer treatments, our firm may be able to help you.  Please sign up for a free consultation on the right-hand side of this page or call our offices toll-free at (855) 828-4100 to speak to one of our consultants and see how our firm can help you.

Mar 24

The Doctor’s Corner: Promising Alzheimer’s and Dementia Studies

Neurodegenerative conditions, such as Alzheimer’s and dementia, are serious diseases that can devastate the ability of an individual to function on their own. For years, researchers have been searching for clues on how these diseases progress, markers for diagnosis in earlier stages, and the best ways to prevent these conditions from progressing. Several new studies have shined a light on some of these issues and provide some promising avenues.

Protein Protects Aging Brain

rest proteinOne of the biggest questions facing researchers is why some people develop Alzheimer’s while others don’t. A recent series of studies published in Nature magazine has revealed that a protein called REST is responsible for stress responses that are activated later in life to protect aging neurons. Specifically, this regulator protein is “switched on” during mid to late-adulthood to protect the neurons of the hippocampus and cortex from oxidative stress and other issues. The absence of this protein is suspected to lead to Alzheimer’s and other forms of dementia later in life.

One study analyzed samples from over 300 individuals who ranged on all measures of the cognitive ability spectrum from normal to severe Alzheimer’s. The study revealed that the levels of REST were strongly correlated with the level of cognition in the patient. This was especially noticeable in the brains of study participants who had some known precursors of Alzheimer’s but hadn’t yet experienced many of its symptoms. The average level of REST in their brains was 3 times the levels of those who were experiencing the debilitating symptoms of Alzheimer’s.

Although this study does leave questions to be answered, it represents a huge leap forward in our understanding of the causes behind many neurodegenerative conditions and how to help diagnose and treat the diseases from progressing. Researchers are rapidly working on follow-up studies to further complete the understanding of this protein that should unlock new treatments for these debilitating conditions.

Alzheimer’s Disease Takes A Heavier Toll on Women

AlzheimersA study to be released in the March issue of Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association reveals some of the primary reasons that studies such as this are so important for women. Updated statistics show that while a 65-year-old man has a 1 in 11 chance of developing Alzheimer’s disease, a comparable woman faces a much higher 1 in 6 chance. This study also goes into the stresses many women experience caring for a loved one with Alzheimer’s disease. The study also confirms the societal expectation that women are 2.5 times more likely to provide full time care for a loved one suffering from Alzheimer’s and are also more likely to put their careers on pause to provide care for a loved one.

The disproportionate effect on women caused not only by Alzheimer’s but also by the expectation to care for loved ones with Alzheimer’s is disturbing and indicates the extent of the financial as well as economic costs to society from all forms of dementia, including Alzheimer’s. The study details one more even more shocking statistic: in a time when everyone is trying to control medical costs, the cost of healthcare for all forms of dementia is soon expected to increase to $214 billion in the United States of which $150 billion will be charged to the struggling Medicare and Medicaid programs.

In keeping with the caregiver focus in the story, the authors also expound upon the 15.5 million caregivers who provide 17.7 billion hours of unpaid, stress-filled work caring for loved ones who suffer from dementia. The total health care costs of these caregivers is estimated to be $220 billion, of which a sizable portion can be contributed to the physical and mental health demands imposed by their caregiving tasks.

As the population continues to age and more baby boomers fall victim to these conditions, health care costs and the burden on the healthcare system will increase until we have better understandings of the causes and treatments for neurodegenerative conditions and find better ways to treat these illnesses.

If you or a loved one are experiencing the signs and symptoms of a neurodegenerative condition or are worried about the stress of dealing with the disability insurance claim process, we can help. Let our firm take some of the stress out of an already stressful situation and help you get the benefits you deserve.

Sign up for a free consultation on the right-hand side of this page or call our offices toll-free at (855) 828-4100 to talk to one our disability claim consultants and see how we can help you.

 

Mar 17

3 Tips To Get Your Rheumatoid Arthritis Claim Approved

diagnosisDuring these cold months, conditions such as rheumatoid arthritis are often more painful and can limit the tasks sufferers can complete in warmer weather. The last thing claimants should have to do during these times is fight for the disability benefits they deserve or defend the benefits they’re already receiving against unfair terminations. We’ve helped many clients through their rheumatoid arthritis claims, so we’ve seen many of the different tactics used by claims departments when they’re trying to find reasons to delay or deny an otherwise payable disability claim. Trying to defend your valid claim is a battle that no one should have to go through, but following these three tips will make sure that the insurance company will not have an unfair advantage during this process.

  1. Make sure to see a specialist for rheumatoid arthritis. Most insurance contracts have a cause that requires something called appropriate care for your condition. This means that you must see an appropriately credentialed doctor and follow a course of treatment that the insurance company’s in-house reviewing physician agrees with to treat your condition. If you’re only seeing your primary care physician or family practice doctor, insurance companies often claim that those doctors aren’t qualified to diagnose or treat arthritis under the appropriate care clause. Having a rheumatologist treat you for your rheumatoid arthritis can defeat these assertions and provide the strong evidence, such clinical examinations and specialized testing, that you need to prove your medical condition to the insurance company.
  2. Don’t rely on alternative treatments for your arthritis. While there may be alternative treatments that help relieve your pain and allow you complete more of your daily tasks, you can’t rely on these treatments alone as the only form of care for your condition. Going back to the appropriate care clause mentioned in the last point, the insurance company physician will expect to see generally accepted, conventional medical diagnosis and treatment in order to accept the diagnosis and treatment. You don’t need to stop any forms of alternative treatment, but it is important to use these treatments in concert with more traditional courses of medicine. By neglecting commonly accepted treatments, you’re giving the claims examiner an easy way to deny your claim.
  3. Accurately report your restrictions and limitations on your claim forms. Like with many other chronic conditions, how you feel with rheumatoid arthritis varies greatly from day to day. When you’re filling out your claim forms, make sure to accurately describe your symptoms and take the time to describe not just a hypothetical average day but go into the variations from day to day. Carefully use examples to describe how you feel and what you can accomplish, bearing in mind that some claim examiners will seize upon the very best of your days as being your average. While saying that you can’t shop for groceries or perform household chores may seem like strong arguments for getting your claim approved, they may hurt your claim in the long run. For example, if you ever feel up to trying to do some household chores (and most people do, at some point) or feel good enough to run to the store for a couple of items, your answers on the claim forms need to reflect this. Making overly broad statements about what you can’t do leaves room for claims examiner to order surveillance that may contradict what you reported on the claim forms and provide an easy reason to deny your claim. Accurately and completely stating your restrictions and limitations along with providing thorough documentation of your medical condition increase your odds for obtaining the disability benefits you deserve.

Rheumatoid arthritis is a terribly painful condition that affects aspects of life for millions of people. By the time you become disabled, the last thing you need to deal with is the frustration and hassle of fighting with an insurance company to get the disability benefits you’ve paid for and deserve. The disability insurance industry has earned a poor reputation for fighting those who deserve their disability benefits, but there are ways to help defend yourself and remove many of the obstacles that have been placed in your way. Following these tips can help you have a stronger claim and let you to focus on getting better and recovering your abilities rather than fighting with the insurance company.

If you have more questions about rheumatoid arthritis and disability claims or would like specific advice about your claim, please feel free to call our offices toll-free at (855) 828-4100 or sign up for a free consultation on the form on the right hand side of this page.

Feb 11

4 Ways to Evaluate Your Disability Claim Settlement Offer

moneyWe receive many phone calls and e-mails from people who want to discuss a settlement offer they’ve received or are curious about a claim settlement from their disability insurance carrier. While a lump sum dollar amount of many settlements may seem big and beneficial, the truth behind these numbers is often harder to decipher. Sometimes, claimants want a disability claim settlement that’s too good to be true, regardless of the high dollar amount that may be associated with it. While not an explicit claim denial, settlement are usually offered to limit or reduce the liability associated with a claim or long term benefit period. Today’s post is going to discuss four different ways to look at these settlement offers and weigh the pros and cons of your possibilities.

  1. Calculate the present value of future benefits. If you have ever taken a finance class or dealt with investments, the term “present value” may be familiar to you. Although many people recognize the term, they may not understand how it’s used. For the purposes of a claim settlement, present value is the current value of a future payment amount discounted by an interest rate for the passage of time. Using a present value calculator, it’s possible to fill in the variables to see what the present value of your future benefit amounts would be, which you can then compare to the amount of a settlement offer. It’s important to understand that the present value of your combined benefits will usually be substantially higher than the amount of the settlement.  Some of the main differences are discussed in the next point.
  2. Pay attention to the mortality and morbidity rates used in the calculations by the insurance company actuaries. Aside from the interest rate, morbidity and mortality rates are two statistical factors that have the greatest effect on any settlement offered by the disability insurance companies. In simplified terms, morbidity rate refers to the likeliness that a claimant will remain impaired and eligible to receive disability benefits. Mortality rate refers to the length of time that a claimant is expected to live and to receive disability benefits. The figures that are used for these rates are seldom provided or explained in a settlement offer. Having an expert who’s familiar with these rates and how they’re applied can be an important part of evaluating whether the settlement you’re being offered is fair.
  3. Consider the taxes that may be due on the benefits. One issue of a settlement that is overlooked by many claimants are the taxes that may come due from a settlement. Since this liability doesn’t appear until a tax return (or returns) is/are filed, it may come as a very unpleasant and unexpected surprise to some claimants who used this money to pay for medical treatments or outstanding bills from their inability to work. If you are considering accepting a large settlement, make sure you discuss any tax liabilities with a qualified expert before making any final decisions.
  4. Consider the emotional and physical stress of the ongoing communications and claim adjudication process with the insurance company. Even if the value of the settlement doesn’t approach the value of continuing benefits, many claimants would rather take a lump sum payment and avoid having future contact with the disability claim professionals working on their claim. Often, the stresses and worries from dealing with these individuals can make many people abandon their disability claim altogether, even without a settlement. Before accepting a settlement for this reason however, it’s important to consider the alternatives, such as hiring a disability claims consultant or an experienced ERISA attorney who can assist with your claim and fight to obtain the benefits you deserve.

While a disability claim settlement offer may seem like a great deal when it’s proposed, significant considerations are required to ascertain the details behind the offer. Disability insurance companies aren’t going to make offers that are detrimental to their bottom line, so it’s important to understand not just your but also their perspectives on the why’s and the how’s underlying a settlement. If you’re medically and financially able, it’s usually best to just continue receiving your monthly benefits and hiring an expert to help with your disability claim if you’re struggling to deal with the on-going communications with and investigations by the insurance company.

If you have any further questions about disability settlement offers or would like specific advice about your claim, feel free to contact us toll-free at (855) 828-4100 or sign up on the right-hand of this page for a free consultation with one of our experts.

Jan 30

New FDA Recommendation to Limit Acetaminophen in Combination Drugs

acetaminophenFDA is recommending health care professionals discontinue prescribing and dispensing prescription combination drug products that contain more than 325 milligrams (mg) of acetaminophen per tablet, capsule, or other dosage unit. There are no available data to show that taking more than 325 mg of acetaminophen per dosage unit provides additional benefit that outweighs the added risks for liver injury. Further, limiting the amount of acetaminophen per dosage unit will reduce the risk of severe liver injury from inadvertent acetaminophen overdose, which can lead to liver failure, liver transplant, and death.

If you are currently on a treatment plan that involved large doses of acetaminophen, please talk to your doctor about the best way to alter your plan to adhere to the new guidelines.

Read the FDA announcement below:

FDA Acetaminophen Announcement

Jan 27

5 Ways to Defend Your Chronic Back Pain Disability Claim

We have a number of clients who suffer from severe chronic back pain that have resulted in their inability to satisfactorily perform their duties and continue in their jobs. Unfortunately, we also see the push back and disputes from claims examiners when disability claims are filed, and we try to help our clients receive the benefits they deserve.

There are many different ways that insurance companies use to fight and deny claims, so it’s important to know the best practices to fight back against their attacks. These five tips are some of the strategies our firm find help our clients suffering from back pain get the disability benefits they deserve.

  1. Make sure your job is well defined and your duties properly explained when submitting paperwork to the insurance company. Often, insurance companies will try and downplay certain aspects of a claimant’s job that are most affected by back pain. For example, a dentist may spend a large portion of their day bent over and twisting, working in their patients’ mouths for both routine examinations and procedures. If you happen to be self-employed or own your own practice, the claims examiner may assert that you spend a majority of your day on paperwork and practice management instead of treating patients. Having proof that you performed procedures and were actively practicing can prove your actual duties and prevent the disability claims examiner from making assumptions about your responsibilities and duties.
  2. Continue to see a doctor and receive treatment throughout the claims process. Although we have severaldisability claimant clients whose back pain isn’t expected to improve in any significant manner, we always tell them to continue to follow their doctor’s recommendations and schedule appointments with their treating physician as often as is suggested by the doctor. While you may not feel like physical therapy appointments are worth the pain or repetitive doctor visits are beneficial to your health, claims examiners can twist that into evidence of a lack of medical care and treatment as an easy reasons to deny a legitimate claim. Even if an alternative medical solution seems to be helping, discuss it with your treating physician(s) before you make any changes to their prescribed treatment plan.
  3. Complete personal narratives thoroughly. When initially filing a disability claim, insurance companies will have claimants fill out a statement or complete a form that specifies the problems or symptoms that prevent them from working. The information on these forms can often make or break a disability claim. Many claimants are assured that they can breeze through these long forms and submit them as quickly as possible. This is rarely a good idea. It’s important to give the claims examiner clear and complete descriptions of your issues and how they affect your ability to perform your occupational duties. If there isn’t enough room on the form, (and there almost never is), attach your own document where you can fully detail your issues and answer the questions.
  4. Complete personal narratives truthfully. Some people think that they should play games and exaggerate their medical conditions, almost like they’re beginning a negotiation. This is a terrible idea. These people tend to be scared and intimidated by the claims process and while they may be truly disabled, they are worried about their claim being denied, so they think that they should exaggerate and stretch the truth to make sure their benefits are approved. This is a bad, bad idea.  Often, these exaggerations lead to more serious claim issues down the road that claimants really don’t comprehend. We’ve seen claims get in trouble after surveillance reveals inconsistencies or after tax forms reflect amounts that otherwise wouldn’t have impacted their disability claim. If you have earned income, report it on your tax returns (and claim forms, if needed). If you are able to perform a few sporadic tasks some days, make sure you don’t report that you spend your entire day, every day, in bed. Insurance companies hire experienced and well equipped investigators who can provide information to leverage such inconsistencies to delay or deny benefits. And ironically, if these types of facts had been appropriately reported in a thoughtful and strategic manner, they likely would not have even damaged the claim.
  5. Always keep your cool. With issues such as chronic back pain, you may feel utterly and completely disabled even if claims examiners can’t or won’t immediately grasp the issues. Having people doubt you, especially your claims examiner and the doctors hired by the insurance company, can be discouraging and even infuriating. It’s important to keep your calm and continue to fight for your benefits in manners that can have positive effects on your claim. To many claims examiners, yours is just one more case on their pile, and your getting angry or making threats won’t help your benefits get approved any quicker. In fact, the opposite will usually happen. Considering your medical conditions, your time and energy is not unlimited. Use what you have to build a team to support you and then work together to build a stronger case for your claim to eliminate any reasons the claims examiner may have to deny the benefits you deserve.

Chronic back pain is a very difficult and overwhelming struggle but getting the insurance benefits you deserve shouldn’t make the struggle worse. Even if you follow the tips provided above, there’s no promise that the insurance company will do the right thing and approve your claim to provide the income you need to support yourself. If you or someone you love is having issues with a disability claim resulting from chronic back pain, our firm can help. Call us toll-free at (855) 828-4100 or fill out the contact form on the right-hand side of this page to fine out how we can help you get the benefits you deserve.

Jan 20

Court Review: Discretionary Authority and Unfair Denials

gavelThe rules and regulations that govern the disability insurance claim process are constantly being addressed and clarified by the judicial system. Decisions are being made every month that could potentially have an impact on your disability insurance claim. Keeping up with decisions on these matters is an important aspect of staying ahead of the learning curve in many disability claim departments. Of course we aren’t lawyers or a law firm and don’t offer legal advice - if you have matters that can only be handled by an attorney, you should consult with the licensed attorney of your choice.  In today’s blog, we’re going to outline a few recent cases that affect disability claims.

  • Court Attempts to Clarify Confusing Wording in Disability Plan: The 4th U.S. Circuit Court of Appeals has stopped a claim denial and ordered the lower court to take another look at the issues involved in a denial of long term disability benefits. Beth Cosey filed a suit against Prudential Insurance Company after they stopped paying her long term disability benefits, even after agreeing that she should receive the benefits based on her disabilities, including low blood pressure and sleep apnea. After three weeks of receiving benefits, Prudential notified Ms. Cosey that she would no longer be receiving disability benefits as she failed to “submit proof of continuing disability satisfactory to Prudential.” The claims examiner insisted that the policy language gave them the discretion to review any and all policy-related terms. Essentially, Prudential wanted to be able to review the disability benefits that a claimant was receiving and, right or wrong, be able to stop the benefits from being paid without any possibility of judicial review. The Court of Appeals concluded that the phrase in this policy attempted to be leveraged by Prudential did not give them discretionary authority and that the language in the plan must be more clear and obvious to allow insurance companies to make claim decisions without any judicial review. If your claim’s been affected by your insurance company asserting their discretionary authority, you may be able to recover disability benefits that were denied due to their incorrect attempt to seize authority that their (i.e., your) policy doesn’t give them.
  • Doctor Eligible for Benefits After Losing License: In New York, the 2nd Circuit Appellate Court ruled that even though a doctor had lost his license to practice, he was still eligible for disability benefits under the sickness provision of his policy. The doctor had lost his license after the state ruled his continued practice caused imminent danger to the health of people in New York. After losing his license, he was diagnosed and treated for bipolar disorder and drug addiction, at which time he filed a disability claim. Northwestern Mutual Life argued that because the claimant had practiced medicine up until the point his license was revoked, his lack of employment was due to the loss of his license, not the underlying medical condition that caused him to lose his license in the first place. The claimant successfully argued that the loss of his license was due to his drug addiction and bipolar disorder, so his inability to work was caused by these conditions as well. Since these conditions were present before the loss of his license and caused the loss of his license, the court ruled that these conditions were the primary cause of his inability to work and the loss of license was only a secondary reason. This ruling means that even if you have lost a professional license or certification due to a disability, your insurance company cannot use this loss of accreditation alone as a reason to deny your claim unless it’s specifically listed as an exclusion in your policy.

One or more of these cases may have some impact on your disability insurance claim. Unfortunately, many disability claims are honestly but inadvertently poorly prepared or submitted by claimants who can be pushed into litigation by a “just say no” claim department philosophy. If you have any questions about how these decisions may affect your disability claim or are worried about where the decisions or actions of your disability insurance company may lead, please call our offices toll-free at (855) 828-4100 or sign up for a free consultation to learn more and get help with your claim.

Dec 18

University Programs in Disability Studies

cap and diplomaIn the ever changing landscape of the world of disability insurance, it’s challenging to stay on top of the most current news and methods. In today’s job market, college students face challenges in finding work in the field of study. An increasing number of universities around the United States are providing solutions to these dilemmas by offering degrees, minors, or certificates in disability studies. From Hawaii to Texas to Iowa, universities are realizing the importance and value of disability insurance.

With 15 to 20 percent of people in the United States having some type of disability on top of the overall aging of our population, this topic is bound to become a more important part of many people’s lives. If you or a loved one has ever thought about disability insurance, you’re aware of the effects that a disability can have on your most important asset – the ability to work and earn an income. By teaching more college students about disability, its history, and its applications, graduates of those programs who are entering the disability insurance business should be better prepared to understand and protect those who need their help. Graduating college students will hopefully be more prepared with the most current information and theories. This academic education should provide a stronger foundation for those selling insurance as well as those handling claims.

Three of the new university programs that have begun to gain attention around the country are at the University of Hawaii at Manoa, the University of Texas at Arlington, and the University of Iowa. While all three universities have taken a different path to educating their students on the subject of disability, it’s a telling sign to have three separate programs at three universities regarding disability. While each program offers a different approach to the topic, it points to the influence that disability and disability studies is having on our population. It’s encouraging to see that even universities and college students realize how complex disability can be at times and want to study and understand more about the disability system in our country to help with its repair and improvement.

 

 

Dec 16

The Doctor’s Corner: Fighting Chronic Back Pain

Back pain is one of the most common reasons that Americans go to doctors, with back pain cases accounting for roughly 10 percent of all primary care visits every year. The treatment of back pain alone exceeds $86 billion a year in the United States. Back pain occurs in all segments of the spine – cervical, thoracic, lumbar, and sacrum. Common pain causing conditions include not only spinal structural defects but also nerve and muscular problems, degenerative disc disease, and various forms of arthritis.

Chiropractic-Treatment-for-back-painDue to the commonness and physical restrictions of back pain, disability insurance companies process thousands of claims each year citing back pain as a disabling condition. Insurance companies have developed special processes for handling these claims – which are called “orthopedic claims” in the business – which has made those types of claims increasingly challenging for those claiming benefits, especially in light of recent medical advances and improved treatments for back pain. We’re going through three recent articles to discuss what your disability insurance company is or is not looking for in orthopedic claims and how that compares to the medical care and treatment commonly prescribed by doctors. We work with many clients who suffer from back pain, with their most common complaint being that the treatments try to mask the symptoms rather than fix the underlying cause of the pain. That being said, disability insurance companies have certain expectations for what they consider to be appropriate care and treatment that sometimes leave claimants facing dilemmas about what procedures to have and when to have them.

Helping Your Doctor Understand and Balance the Relationship Between Your Treatment Costs, Your Back Pain, and Your Disability Claim: Researchers from Beth Israel Deaconess Medical Center in Boston have discovered that many doctors are not following current research and recommendations in diagnosing and treating back pain. Instead of treating back pain with more conservative procedures at first, such as basic NSAID medications and physical therapies before working up the hierarchy of medications, some doctors immediately jump to more advanced treatments, such as CT scans or MRI’s and narcotic pain medications, at the beginning of diagnosing and treating their patients. Obviously, these treatments are much more expensive. But if you have back pain and want relief quickly, doctors will often do the best they can for their patients even if it goes against current medical protocols.

This situation is compounded if the patient is also filing a disability insurance claim. The insurance company is going to review the medical records to assess the severity of the medical condition and the associated restrictions and limitations. Nurses are employed to work with claims examiners who may insist that advanced tests and scans are needed to document your medical condition for the claim. This brings up what we refer to the split-personality of care and treatment in disability claims: Balancing what may be the most appropriate treatments with the assumptions and expectations of claim department personnel as to what treatments should be appropriate.

The most common drugs that doctors prescribe for their patients who have back pain and are disabled are no longer NSAID’s. Instead, due in large part to the expectations of insurance companies, doctors have started using more narcotic medications to treat back pain. These drugs, while much more effective in masking pain than NSAID’s, can be problematic due to the risk of increasing tolerance and of addiction.

As both a patient and a claimant, you and your doctor face a dilemma of choosing between options. You could choose milder (and less expensive) treatments that may effectively treat your condition but will likely lead the insurance company to reject your disability claim by asserting that your medical conditions must not be that serious if you’re able to treat it with such a mild treatment. On the other hand, you can have more expensive radiological studies performed and be prescribed narcotic painkillers, which may also effectively treat your condition and will be much more likely to convince the insurance company that your medical condition is sufficiently severe to warrant disability benefits at the increased risks of addiction and at higher costs.

Additional Risks of Steroid Injections for Back Pain: It’s been known that steroid injections will eventually decrease bone density. A new study though has shown that for older patients, steroid injections in the spine increase the likelihood of spinal fractures. Steroid injections are commonly used to treat back pain, as they can be an effective but short-term solution to overwhelming back pain. This new study highlights some of the risks that patients have to face in order to create stronger documentation for a disability claim. If you decide to forego steroid injections due to the associated risks, you need to be aware of the expectations of claim examiners. Your disability insurance company may assert that your back pain must not be debilitating if you’re declining treatment. They may view steroid injections are a reasonable treatment for back pain and will pressure you to exhaust all possible treatments to qualify for your disability benefits, regardless of the risks associated with this treatment. You and your doctor should carefully consider the pro’s and con’s of steroid injections as well as alternatives before deciding to purse that treatment for your back pain.

A New Treatment for Lower Back Pain: A new study is experimenting in using stem cells from a patient’s own bone marrow to treat lower back pain. The study tested a small number of patients, as the treatments are not yet covered by most medical insurance companies and are tremendously expensive. As the trials for this treatment have been so small, there still needs to be considerably more research before this treatment becomes generally accepted and available to treat back pain. However, any ground-breaking treatment for back pain that actually cures the source of the pain as opposed to simply masking the pain is certainly welcome news to anyone who’s suffered or is suffering from back pain. If stem cell treatments are found to be effective, they would certainly become a standard option for curing the medical conditions that cause such debilitating back pain. And best of all, our clients could become pain free and regain their lives rather than having to continue fighting the disability insurance companies to keep the promises made in the policies they sold.

If you or someone you love is having issues with the insurance companies in handling your back pain disability claim, we can help. Please fill out the contact form on the right hand side of this page or call our offices toll-free at (855) 828-4100 for a free consultation to find out how our firm can help you.

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