INSURANCE COMPANY TACTICS FOR DENYING A LONG-TERM DISABILITY CLAIM
Dec. 3, 2021
WHEN AN LTD CLAIM BECOMES NECESSARY
People with lupus, multiple sclerosis, fibromyalgia, arthritis, spinal stenosis, depression and other serious conditions often work with serious challenges that many people do not understand. Despite engaging in a heroic struggle to remain on the job, a person afflicted with such a condition may reach a point where he or she can simply no longer work full time or work at all.
Insurance companies understand well the challenges facing people afflicted with serious medical conditions. However, rather than pay a well-supported disability insurance claim submitted by an honest, hardworking person compelled to cease work, many insurance companies search for every possible way to deny such claims.
Insurance Company bad faith tactics to deny legitimate LTD claims:
1. HIRING A DISHONEST “INDEPENDENT” DOCTOR TO CREATE A DISHONEST MEDICAL REPORT
One favorite tactic used by insurance companies to deny meritorious claims — and try to make their denials stick — is to hire unethical physicians who will say virtually anything to support the denial. These “hired gun” physicians — whom the insurance company will characterize in their denial letters as “independent physicians” — will conduct highly selective “paper reviews” of an insured’s medical records and inevitably conclude that the insured is not disabled. These highly compensated, unscrupulous doctors often state that the insured’s medical records fail to reveal certain “abnormalities” or “objective signs” of an illness or injury — and, therefore, according to these doctors, the insured is not disabled. In many instances, as the hired gun doctor knows, the absence of certain “abnormalities” or “objective signs” is utterly irrelevant to whether the insured suffers from severe pain or disabled.
With the assistance of an experienced insurance attorney who has been down this path many times before, you can successfully challenge and defeat the insurance company’s bad faith denial. If your case goes to trial, we know what ask your own treating physician on the witness stand and how to ask it. We know how to present truthful testimony to overcome dishonest medical reports in the insurance company’s file and the misleading testimony you can virtually always expect from the insurance company doctors. We know how to prove insurance bad faith.
2. DISREGARDING THE INSURED’S ACTUAL JOB DUTIES
In establishing your entitlement to disability insurance benefits, you should provide to your insurance company with a clear and comprehensive job description. Unfortunately, despite California law that requires an insurance company to find you to be disabled if you are unable to perform your “material” job duties, many insurance companies will simply disregard your job duties in deciding you are not disabled.
If your case goes to trial, the insurance company will have a difficult time explaining why it disregarded your actual job duties in denying your claim. Your insurance company’s disregard of your actual job duties will support a finding of insurance bad faith.
3. SELLING A POLICY CONTAINING UNLAWFUL DEFINITIONS OF “OWN OCCUPATION” AND “ANY OCCUPATION” (OR “OTHER OCCUPATION”) COVERAGES
The insurance company’s bad faith conduct often begins long before your claim is denied. It often begins with the sale of the disability insurance policy itself.
Many disability insurance policies are divided into “Own Occupation” coverage and “Any Occupation” (or “Other Occupation”) coverage. In most policies, the “Own Occupation” coverage lasts for 24 months after which the “Any Occupation” coverage” applies.
“Own Occupation” coverage, one would think, covers you if, due to a disability, you cannot perform your own job. However, many insurance companies insert illegal and deceptive language into their policies to redefine one’s “own occupation” as being some job other than the one you actually performed. More specifically, insurance companies sometimes define the insured’s very particular “own occupation” as a broad category of occupations.
For example, if you are a manager in a particular department of a particular city or county agency, the insurance company will look the job of a “manager” generally and how it is performed in various departments of different cities and counties across the entire country to determine whether you are disabled from your actual and specific job. Often the insurance company will identify other “managerial” jobs that are less demanding and require few hours than your own — and determine that you could perform these other jobs that were never your own. Often the insurance company finds simply that if you can sit a certain period of time, you are not disabled — even if pain, fever, exhaustion and other severe symptoms make it impossible for you to work.
If the insurance company redefines your job as a different job that is far easier to perform, it can more easily deny the claim. An insured can and should confront an insurance company’s ploy to redefine his or her job. A compelling argument can be made that this redefinition is further evidence of bad faith. “Any Occupation” or “Other Occupation” coverage usually applies after the insured has been receiving disability benefits for 24 months.
As with “Own Occupation” coverage, insurance companies often misstate the definition of “Any Occupation” (or (Other Occupation”) coverage in the policy. Insurance policies often state that in order to qualify for disability benefits, an insured must be disabled from “any” other occupation.
Under California law, “Any Occupation” or “Other Occupation” coverage has a very specific meaning. If your claim is governed by California law, your insurance company can properly deny your claim only if there exists occupation that you “could reasonably be expected to perform satisfactorily in light of your age, education, training, experience, station in life, physical and mental capacity.” In other words, the insurance cannot require that a college professor work as a janitor or a machinist work as a secretary.
In resisting the misrepresentations in the policy as to the acceptable definitions of “Own Occupation” coverage and “Any Occupation” (or “Other Occupation”) coverage, the law is on your side. Both the California and federal courts have upheld bad faith and punitive damages verdicts based on the insurance companies use of unlawful definitions of disability in their insurance policies.
CONTACT THE LAW OFFICES OF BENNETT M. COHEN
At the Law Offices of Bennett M. Cohen, we represent individuals throughout the Bay Area in long-term disability insurance claims. We have successfully confronted and overcome insurance company tactics for our clients and are committed to doing so for you. If you choose our firm, you will have an aggressive, tireless team representing your interests. (See the results and client testimonials.)
At our firm, the first consultation is free. Please contact us to schedule a meeting with our San Francisco long-term disability claim lawyer (LTD claim lawyer) to discuss your case.