So You Thought You Had Disability Insurance About Long Term Disability Insurance:
Insurance companies are corporations, and corporations exist to turn a profit. In the 1980s, when interest rates were sky high, insurance companies competed heavily with each other for your premium dollars in order to invest those dollars at high rates of return. This was particularly so with disability policies.
This stiff competition drove insurance companies to:
- make policies non-cancellable (without ever raising the premium) and payable until age 65 or life;
- make the policies occupation specific (as opposed to policies that say you are only disabled if you are unable to perform any occupation);
- broaden the conditions that are covered (including herniated disks, heart conditions, psychological illnesses and cancer);
- include the cost of living increases; and
- under-price the policies.
The gamble paid off. Premium dollars poured in and insurance companies realized substantial profits on their investments. But gambling is always risky business. When interest rates plummeted in the 1990’s, so did the profits of insurance companies.
Major insurance companies were forced to increase reserves (the amount insurance companies must put aside to pay present and future claims) by hundreds of millions of dollars. In 1993, one of the largest disability insurance companies in the United States took a “charge” of over $430 million. The president was replaced by a banker with no previous experience running an insurance company. He, in turn, appointed a finance and tax expert (who also had never handled an insurance claim) to run the entire claims department.
The claims handling department began to change. Incentives were provided to some executives (including large stock options) to increase profits. Employees, who are obligated to treat claimants fairly and with patience, were instead given rewards for denying or terminating claims. “The Hungry Vulture’s Award,” with the slogan “Patience my foot, I want to kill something.” Some people were told to destroy documents that might embarrass or incriminate the company in court.
This effort to increase profits in the 1980s was not limited to a single insurance company. Many companies from eh 1980s were desperate to capture the market share, and did so by writing favorable policies, particularly in high-market states like Florida and California. But in the 1990s, these same companies became equally desperate to avoid paying the benefits they had promised.
Policyholders who suddenly found themselves unable to engage in their occupations were surprised by the response of the insurer after filing a claim. Many claimants were followed by sub-rosa investigators, and subjected to video surveillance.
“Independent Medical Examinations” were scheduled and performed by hand-picked doctors, often chosen for their skill in forensic (courtroom) work and their likelihood of favoring the insurance company’s point of view. The opinions of treating physicians were often ignored.
Other innovative techniques were utilized, all with a single goal, as so eloquently put by one former insurance company vice-president, “Look under every rock” for any “loophole or excuse” to terminate benefits.
Insurance companies neglected to train claims adjusters so that adjusters would not know or understand their obligations to policyholders. No training materials, guidelines or instruction programs were given to teach adjusters how to handle a claim, define policy terms, or describe medical conditions.
Some insurance companies even delegated their entire claim investigation responsibility to outside adjusting firms in order to distance themselves from the fact-finding process. And others purposely avoided conducting simple medical or occupational tests that might confirm the claimant’s disability.
In another case, the company offered to buy-out a dentist’s policy for $300,000 knowing that his future benefits were worth over $4 million. It bluffed that if he refused, the company would deny his claim and close the file. He called their bluff.
Unfortunately, in many cases, disabled policyholders simply give up or under-settle for nickels on the dollar because they are too ill or injured to deal with the insurance onslaught.
With all this in mind, take heed of the following questions and answers. They may assist you in protecting yourself against the very company you pay to protect you.
The "Own Occupation" policy.
This type of policy insures you against becoming unable to perform “the substantial and material duties of your own occupation”. This coverage pays a monthly benefit if you can no longer perform the specific tasks of your work (as a contractor, for example, or as a dentist, etc.) Benefits with this type of coverage are paid regardless of whether you are able to perform other types of work.
A. “Own Occupation” means that you are unable to perform the substantial and material duties of your own occupation at the time you become disabled. If you cannot perform those duties in the usual and customary manner because of a disability covered by your policy, then you may be disabled.
There is no numerical test. The issue is whether your illness or injury precludes you from performing your job normally and with reasonable continuity. For example, an insurer, in the interest of saving money, cannot require that an individual, who suffers from permanent back pain after a failed spinal surgery, to go back to work in pain.
A. “Modified Own Occupation” policies are becoming more common. These policies usually protect from disability in your own occupation for five years. Thereafter, they convert to “any occupancy” policies.
“Any occupation policies, though important, aren’t as specific as “any occupation” policies. They protect you when you are disabled from performing any occupation based on your experience, age, education and training.
A. You have to look at the particular policy language (and exclusions).
A. The most important proof is to have honest, board-certified physicians or psychiatrists (if your policy covers psychological disabilities) certify you as disabled. The physician should also state what your limitations and restrictions are and why you cannot perform your occupation or another occupation. It is extremely helpful to have objective findings of disability, such as x-rays, MRIs, MMPIs, functional capacity evaluations, etc.
However, even with qualified physicians and objective evidence, some insurance companies will deny or terminate benefits based on conflicting opinions of in-house medical consultants or hand-picked “independent medical examiners.” Insurance companies often employ such tactics to justify underpaying a claim or offering a buy-out of the policy. When this occurs, do not be deterred. Your treating physician should respond in writing to medical opinions challenging your disability.
A. Good question. It all depends on the definition of disability contained in your policy. Some policies distinguish between “own occupation” and “any occupation” and “total disability,” “partial disability” and “residual disability.” Subtle differences can make a big difference in the method used by claims adjusters to evaluate your claim.
This means you want to know what the definition of disability is and you want the doctor to comment on it. Insurance companies may later quiz doctors. Unless doctors know the definition of disability, their innocent comments will be taken out of context and used to justify claim denials and terminations.
A. When an insurance company unreasonably denied or terminates a claim, it may be forced to pay what it owes from the past (plus interest); what it owes in the future; payment for emotional distress; some attorneys’ fees; other costs and expenses; and, if the requisite intent is present, punitive damages.
A. Yes. And it does happen, often.
A. Write a rational letter to the claims manager setting forth your position, and ask for the company to reconsider its decision. Ask your treating physician to respond. If necessary, ask an attorney specializing in such matters to review the letter.
Sound serious? It is. To some people insurance is a bottom line.