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Contributed by Disability Insurance Bad Faith Attorney, Eric Ratinoff

So you’ve become disabled.  You’ve paid premiums all these years. You’ve done everything you’re supposed to do. You made your claim, you provided documentation and information to the insurance company. You filled out their forms, you gave them permission to get your medical records, including permission to talk with your doctor, if they want to.

Now what does your insurance company have the obligation to do?

First and foremost, they have the obligation to promptly and thoroughly investigate your claim. That doesn’t mean just look at what’s convenient for them. They have to affirmatively look at the records and get any records that they don’t have that they think may support your claim. And that’s an important point – an insurance company in California cannot just look at information that supports their position that you’re not disabled or that there isn’t coverage in your policy. Every insurance company in California has an affirmative obligation to seek out evidence of coverage, not simply seek out evidence that helps them deny coverage.

Insurance policy holders have a very important right to hold their insurance company to the standard that they have to put policy holders’ interests on at least a high a standing as they put their own. And that’s a powerful tool.  Insurance companies have to investigate, and they have to do it quickly. They have to pay you timely. They have to seek out information that supports your claim. And they have to communicate.

Insurance companies are not allowed to be dishonest with you. They are not allowed to tell you that there’s no coverage when in fact there is. They are not allowed to undercut your claim because it’s convenient or profitable for them.

In so much of the world and the way that we see big business doing business, companies put profits over people. An insurance company, in handling your claim, absolutely is not allowed to put profits over you. It’s people over profits. They have got to do their job, and they’ve got to do it well. They’ve got to do it quickly. And they have to seek out information that supports you.

Let’s talk about the medical review doctor for the insurance company. This is somebody who earns his or her living from the insurance company that makes money by collecting insurance premiums but not paying claims. So this doctor will look at the records and say, “gee whiz, I disagree with the treating doctor,” the one who’s treated the insurance policy holder for 15 years, who knows the record inside out, who’s visited with the patient many many times over the years. He’s actually drawn the blood and had the conversations and done the physical examinations and all the work that doctors do when they’re doctors who treat people and understand people and know their patients. But the insurance company has someone there in house on their payroll who will look at the records and say, “well, I disagree with the doctor who actually knows what he’s talking about.”

There’s no misunderstanding why that happens. The question is what do we do about it? And what’s an insurance company’s obligation? It’s certainly to do more than that.

Now, has that doctor gotten on the phone with the treating doctor? Has he inquired about what the doctor wrote in his records about the patient? They don’t do that, but they certainly should if they’re going to disagree with that doctor.

And why doesn’t the insurance company doctor perform a physical exam? If there’s additional testing that needs to be done, why not get that done? They have an affirmative obligation to do it if they’re going to deny a claim. Where there’s medical support, they can’t simply disregard your good medical evidence. It doesn’t work that way in a private disability insurance policy in the state of California.

If your insurance company’s playing those kinds of games, you don’t have to put up with that. Get somebody – an attorney or another representative – to step forward and help you make your best case.

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Contributed by Disability Insurance Bad Faith Lawyer, Eric J. Ratinoff

So let’s take a few minutes to talk about what happens when you become disabled.

Here you are somebody who’s purchased a long term disability policy to protect you and your family, and calamity strikes – either an accident or an illness – and you can no longer work.  What you should do is immediately make a claim with the insurance company.  There’s a claim form that you can easily obtain – call your agent, call your broker, call the insurance company directly.  Let them know that you’ve been injured, or that you’re sick, and you’re making a claim under your policy.  And you should start to fill out the claim form right away.  Get it back to them promptly.  There will be statements that will need to be filled out by your physician, so make sure to get the form to your doctor as soon as possible.

Now, every disability policy has a provision stating that you need to be under the regular attendance of a physician for the disabling condition to be valid under the policy.  What “regular attendance” means is up for interpretation, and, really, that’s a medical issue to determine what’s regular and what’s reasonable according to the condition that you’re suffering.  It must be established that this is a condition that’s affecting your life to the point that you can’t do the job you’ve trained to do for so many years.
It’s also important to start gathering documentation that will help you put your best foot forward with the insurance company.  Get your medical records together if you are able.  Gather whatever films may have been taken.  Let your insurance company know that they can have it all.  Now the insurance company has forms that allow them to get your medical records themselves – and they should do that.  It’s their obligation to do that.  But they don’t always do it. And whenever possible, you as the claimant need to force their hand.  It’s understandable that you may not be able to gather everything – that perhaps because of your condition you simply cannot manage to pursue the necessary documents or even keep them organized.

That’s one of the sad things about how these insurance companies treat people, because often it’s a disabled person who’s down and out and lacks resources and is sick, disabled, that the insurance companies take advantage of.  And they have you jump through hoops.  They’re not supposed to make you jump through hoops, but sometimes they do.

So get your documentation – your medical records, your earning information.  Get your W2’s. or if you’re self employed, get your 1099’s.  Gather together your tax returns.  All of this information comes together and may provide support for your claim.  Every policy contains something pertaining to earnings, and almost every policy calls it “proof of loss,” or some version of that phrase.  In essence it’s the proof that your claim is valid and falls under the provisions of the policy.  This is the type of information that helps prove that.

If you were injured on the job and you have a vocational rehabilitation counselor that’s been working with you through the worker’s compensation system, get that documentation together.  If you’ve applied for social security disability and have been deemed disabled according to social security, get that documentation together.  But don’t be misled – the definition of disability under most insurance policies is far more favorable to you as the insurance policy holder than the definition of disability under the social security guidelines.  So if social security says you’re not disabled, that doesn’t mean that you are not disabled under your insurance policy.  They are two different worlds.  But certainly, if the social security has said that you are disabled, that’s very powerful evidence to get in front of your insurance company to support the proof of your claim.

It’s important to get as much documentation as possible to make it difficult for the insurance company to deny your claim.

Stay tuned to part three of this 4-part Disability Claim series.  To subscribe to this series via podcast, visit the KCRLegal Personal Injury Podcast.