Disability Insurance: After A Claim Is Filed: Following Up
After the claim is filed:
- The insurance company will request your medical records from your doctor(s). If there are mental symptoms, they will also request records from your mental health provider. After receiving these records, the insurance company will review your claim.
- In determining eligibility for benefits, there is no set standard for when a person is "disabled". Instead, each insurance company looks at the definition of "disability" under the particular contract to see which standard to apply. The insurance company looks at:
- Your medical condition and how it impacts your ability to work and
- Your job description which determines what work it is that you can't do.
- During the process, the insurance company may request:
- An examination by a company appointed doctor (a "Consultative Examination."
- That additional questionnaires be completed.
- That you meet with an investigator.
Usually, the insurance company will send a letter acknowledging receipt of the claim and giving the name and phone number of the person handling it. If you don't get such a letter within a couple of weeks of filing, consider calling the company and trying to find which Claims Representative has your claim. See Talking to Your Insurance Company. It is advisable to call that person. Introduce yourself. Make sure that he or she has received everything needed and that the claim is "in process".
- It is too early to start asking how soon you'll have your first check and it's probably too early to ask when the company will agree with your claim. Instead, consider telling the representative that you wanted to make sure he or she got everything that is needed -- and that he or she should feel free to call you with any questions or requests for more information.
When you know the the claims representative is, it is advisable to:
- Introduce yourself to the claims representative and ask if any additional information is needed to approve your claim.
- Keep following up. To learn how, click here.
- During the decision process:
- You may be asked to take a physical exam (known as a "Consultative Examination"). As a practical matter, you have to take the exam, but not necessarily by the company's doctor. To learn more, see: Consultative Examination.
- You may be asked to answer supplemental questionnaires. If so, do so in the manner most likely to get approval of your claim.
- During the claim review process, the insurance company may send an investigator to meet with you. It is recommended that you learn how to handle such a situation now "just in case." If not now, at least learn your rights and how to handle the situation when you receive a request to meet. See: If An Investigator Comes Calling.
Sometimes, an insurance company will send supplemental questionnaires to complete. Questionnaires can vary depending on your symptoms. For example, if fatigue is one of your primary symptoms, you may be sent a form requesting information about "Your Daily Activities", such as asking how you spend your day, how you keep house, how you do shopping and errands etc. If you have been experiencing pain, you may be sent a "Pain Questionnaire." As you answer the questions, keep in mind how each of the symptoms affect your ability to do your job or your daily life activities. If you have been keeping a Symptoms Diary, it will make these questionnaires easier to complete and more accurate. In turn, this can translate as more persuasive to the insurance company.
How To Follow Up On Your Disability Claim It is advisable to follow up regularly without being a pest. You can start by calling every other week. You will quickly learn if it's too frequent. Often, too, you will get an idea of how far to space your calls by what is going on with the claim. If the company is waiting for information from one of your doctors, then call a few days after your doctor mails the information. If, however, the entire file has been sent out to their "medical consultant" for review, it probably will be there at least three to four weeks.
It's too early to make an enemy out of the claims processor; that can come later if necessary. Right now is the time to be as helpful as possible. A brief call to "just check in" is all that's needed. Ask if he or she is waiting for any information that hasn't come in. If so, find out from whom and then call that person yourself and push to get the material in.
The insurance company is in no hurry. It's up to you to make sure all requests are handled properly. See Talking to Your Insurance Company regarding making notes of phone calls.
If the claims processor tries to obtain information from you over the phone, politely ask him or her to send you the questions in writing adding something like "I don't remember things real well and I don't want to give bad information." Just as you took time completing the form originally, you want to have time to think about any additional questions you're asked so you don't say the wrong thing. We've known of claims departments to record conversations. Once you provide an answer, it becomes part of your record.
If your claim is approved, payments will begin at the end of the month following the completion of the elimination period. For example, if the policy says that it does not pay for the first 30 days of disability, if you leave work on disability on May 15, there is no coverage at all until June 15. Since disability policies pay after you are disabled, you won't receive a check for the period June 15 to July 15 until after soon after July 15.
Make note of your continuing obligations, if any. They will generally be described in the letter approving your claim. If they aren't contact the insurance company to find out what your obligations are.
It is likely that your claim will be subjected to periodic reviews over time - including the possibility that the company will send an investigator to interview you.
It is advisable to know your responsibilities and the company's rights while you receive benefits.
If the claims person tries to deny the claim over the phone, insist that the denial be put in writing to you as soon as possible. Be sure that the written denial explains:
- The reasons for the denial.
- Your right to appeal.
- Any time limit during which you must file your appeal.
Under the federal law known as ERISA which covers all employer based plans, the insurance company is required to notify you in writing and give you the reasons for the denial.