Often, the insurance company will accept an insured’s claim when it is in the “own occupation” period, but then, when the policy switches to “any occupation” the insurance company will claim the individual can perform some job for which he or she possesses knowledge, skill or training. Basically the switch from “own occupation” to “any occupation” allows the insurance company to manufacture an excuse to terminate benefits by claiming the individual is able to perform some job function.
The insurance company usually terminates benefits based on how the individual’s job is rated. Jobs are rated based on whether they are a sedentary occupation, light-duty occupation, medium-duty occupation, or heavy-duty occupation. If the individual’s “own occupation” is rated as medium-duty, the insurance company will claim the insured can perform a light-duty or sedentary occupation to terminate benefits at the “any occupation” stage.
A disability insurance company may send a field investigator to follow the individual to take surveillance video. Then, based on the snippets of that surveillance video and a one-sided report of what that field investigator saw, the disability insurer would claim that the person is making up their injuries.
This happens especially if snippets of the video show that the person for a “split second’” performing an activity the insurer contends shows the individual is more capable of working than they are claiming. When fighting a denied claim based upon surveillance video evidence, an experienced disability insurance lawyer might argue that the video was just for a short period of time and doesn’t show how the individual was incapacitated afterward because of that activity.
Although the insurance company is saying that based on a short segment of video that the individual can work a 40-hour workweek, a counter argument is that segment doesn’t prove that the individual can work a 40-hour workweek or even eight hours in a day. What they can do for short bursts of time isn’t always what they can do for 40 hours.
Another approach is to show that the surveillance itself is biased. The investigator takes notes when he is out there and could skew his notes and makes it appear as though the person is a lot more capable of movement. Sometimes, we can show that this investigator is getting all of his work from insurance company XYZ, and knows he is hired to show in his video footage that people aren’t disabled. So, it makes it a biased standard. The only reason this investigator is out there is to deny claims.
Mental Disorders and Nervous Conditions
Another difficult situation is the disability insurance company’s denial because of a two-year limitation on mental disabilities. The insurer will argue that your injury is a mental disorder or nervous condition in nature, and that they will no longer pay after two years. The insurer will look at the claim, and they will accept the claim initially, but then after two years, they will tell you that what you say is, for example, fibromyalgia is actually a mental or nervous disorder and terminate the benefits.
Additionally, insurance companies will often deny disability claims stating the individual only has “subjective complaints.” The disability insurer argues the individual is just telling the physician he or she has nerve pain, but it is not showing up on an EKG or other medical testing. The insurance company will deny claim as subjective because there are no medical tests that reveal it.
However, that doesn’t mean the claimants aren’t actually disabled. They are just saying there is no objective proof.
There is always the question of whether the insurance company has the right to ignore subjective complaints under the language of the policy and how they are handling claims. It very well could be an improper denial.
Your disability insurance lawyer would argue that even though there are no objective tests, it is the doctor’s belief that the person is disabled and cannot perform the functions of their occupation. So, it comes down to the injured person’s physician’s word against the insurance company’s doctor who will argue that the individual is fine.
Then an experienced disability insurance lawyer would attack the position of the physician who is working for the insurance company. That doctor may do 100 claims for that insurance company in a year, and in those 100 claims, he may report that he never sees anybody who is actually disabled. An experienced disability lawyer will prove the doctor is biased and has clear incentive to give the insurance company the results the insurance company wants.
Not Under a Doctor’s Care
Another common reason for denial occurs when the claimant hasn’t been under the regular care of a physician. If an individual is not attending appointments, they will say it means the individual is not disabled.
In that case, as insurance lawyers for the disabled claimant, we may argue that the individual doesn’t need to be under the care of a regular physician because their condition is such that there is no hope of improvement. If they are never expected to get better, then there is no need for them to keep attending doctor’s visits for that condition.
It also depends on the language of the policy and what is required. Perhaps they are meeting a requirement of the policy, but the insurance company has a different view of it, as always with their own monetary interests in mind.