Surgery Doesn’t Always Do the Trick: What to Do If You’re Not Ready to Work But Your Disability Insurer Insists You Are?
To the insurance company, the issue is simple. You suffered an injury that prevented you from working. You had surgery to repair the damage. You will recover from surgery in the predicted number of days, and you will be ready to return to work. So your disability benefits will be discontinued.
However, real life often does not unfold according to predictions and industry guidelines. Surgery may not have been successful. You could need additional recovery time. Or surgery could have addressed only a small facet of the condition that is preventing you from working.
When you disagree with your disability insurer about your eligibility for continued benefits, that’s a significant problem. Long-term disability benefits enable you to continue to meet obligations personally and professionally. So it makes sense to work with an experienced Miami insurance claim lawyer to resolve the dispute quickly and ensure that you receive the full benefits you’re entitled to under your policy.
Understanding Disability Insurance
Professionals, business owners, and others who rely on their work income to support a household or commercial venture often purchase individual disability insurance policies for protection. These policies provide benefits to compensate for lost income when a policyholder is unable to work due to a covered disability.
Companies that provide disability coverage usually sell both short-term and long-term disability policies. As the names imply, short-term coverage only provides benefits for a brief term, often 3-6 months, while long-term policies may continue to pay benefits until the policyholder reaches retirement age. Short-term policies generally will start paying benefits quickly, often within a couple of weeks after the onset of the disability. Long-term policies typically require a disabling condition to have persisted for a specified period, known as a waiting period. This period could be as short as a month, but it is usually 3-6 months. Ideally, disability policies should combine to provide continuous coverage from soon after the disability begins until the disability ends or the policyholder is expected to retire.
Disability Claims Must Be Maintained
When a policyholder is approved for benefits under a long-term disability insurance policy, the insurance company will not expect to pay benefits indefinitely. In fact, they may be looking for a reason to discontinue benefits from the very start. Some insurance companies have been known to hire detectives to follow policyholders who are receiving benefits to record their actions and assess whether they are truly as disabled as they claim to be.
Policyholders receiving benefits must be aware that they need to take care to maintain their claim in order to continue receiving those benefits. When the insurance company expects an updated report from the doctor about the disabling condition, it is essential to provide that report in a timely fashion, even if the insurance company doesn’t remind you that your policy requires it. Remember, they are looking for reasons to stop paying benefits. Collecting regular and thorough reports from doctors about your condition not only ensures that you’re fulfilling your contractual obligation to the insurance company, but it also provides valuable evidence to dispute any assertions they make about your ability to return to work.
When You Receive Notice That Your Benefits Will Be Discontinued, But You’re Not Ready to Work
When you and the insurance company disagree about your eligibility to continue to receive benefits, you need to act to secure your right to appeal the decision. The action necessary should be described somewhere in the fine print of your policy. You may be required to submit certain forms to the company to request an internal review before you can challenge the insurance company’s action in court. A Miami insurance claim lawyer may be able to negotiate reinstatement of benefits upon the presentation of additional evidence.
If the company has decided that it will no longer pay benefits because the computer program they use indicates that surgery for the XYZ condition should have restored you to full functionality by now, then they may not be anxious to hear evidence to the contrary. They may request that you undergo an “independent medical examination” to assess the extent of your disabling condition. The doctor conducting this examination will be on their payroll and will be reporting evidence to support their assertions.
It is often necessary to obtain additional medical examinations and opinions from vocational experts to show the extent to which your disability continues to prevent you from practicing your profession or working in the capacity that you need to perform your job. An experienced insurance attorney can help acquire the evidence you need and present that evidence persuasively, either during an internal appeal process or in litigation. If the insurance company is acting in bad faith, your attorney may be able to recover additional relief.
Documenting Your Condition
While medical records and written opinions from a physician will provide critical evidence to support your claim for continued benefits, there are additional ways you can strengthen your arguments and increase the likelihood that the insurance company will be required to reinstate benefits. One way to do this is to keep a journal that documents your symptoms on a daily basis. Explain what you are experiencing and the effect that it has on your ability to perform everyday tasks, particularly those that require the same skills you need to perform your job.
In addition, you may be able to use testimony from people who see you regularly, such as neighbors who can explain that before your injury, they used to see you regularly performing vigorous activities such as yard work, but since the injury, they only see you leave the house occasionally to get in the car for doctor’s appointments. Presenting a variety of evidence to demonstrate the ongoing impact of your disabling condition can be highly persuasive.
When the Insurance Company Fails to Honor Their Obligations Under Your Policy, Ver Ploeg & Marino Can Help
Insurance companies can get very creative in the ways they try to justify cutting corners to save money. When they have the opportunity to stop paying benefits, they will often take it, even if the policyholder still clearly qualifies to continue receiving payments under the policy’s terms.
Disputes with insurance companies can become very complicated, and the insurance company will be represented by corporate lawyers who spend all their time developing the best legal arguments to deny paying out claims.
If you want to secure the benefits you deserve under your policy, you need to fight back with legal acumen and a thorough knowledge of the insurance industry. At Ver Ploeg & Marino, we have focused our practice on resolving insurance disputes, drawing on decades of experience that have enabled us to succeed where others have failed. For a confidential consultation to discuss how we may be able to assist you in your situation, please call us at 305-577-3996 or contact us online now.
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