Profit is made by insurers by acquiring premiums, investing the proceeds, and paying claims in hope of making more money from the investments in the interim period. Here is the catch. They have actuaries who compile the statistics and set premiums to guarantee a profit. So, the only way to create an even larger profit (or as I term it, a windfall) is to deny merit worthy claims and waiting to see if claimants have the capacity to fight the claim denial.
On the surface this seems unfair and cold, but is actually far more devious than meets the eye. You see, the insurers know how to pick their victims. Who better than disabled persons who are living on a limited budget (funded in part or in full by the insurer) and tend to be focusing on improving their health and maintaining their families than paying attention to the insurer’s activities. The insurers know that kicking a person when they are down is the best time. A benefit termination will instantly overwhelm the claimant and place both economic and time pressures on this already impaired individual. The insurer hopes the claimant will simply give up or will be unable to locate a competent counsel to assist them.
Of course, the insurer will not directly approach the claimant and tell them they are conducting an investigation. At best, you may receive an innocuous letter stating that they are conducting a review of some sort as part of their “ongoing investigation” of your claim. As part of this routine inquiry, the insurer may be undertaking any of the following unsavory activities:
1. Direct Provider Contact. This is comprised of having an internal nurse or physician contact your treatment provider(s) in order to acquire statements which can (and will) be utilized to deny your claim. This may include the infamous “what we discussed” letter which concludes with a statement that if your provider does not respond then the statements will be deemed truthful. (How nice)
2. Background Information Check. The insurer will research your assets including your vehicles, real estate, bank accounts, and credit information. The insurers want this information to find out if you have sufficient resources to “sustain litigation” if they decide to deny your claim. (Double goody)
3. Active Surveillance. This is the favorite of my clients. The insurer will hire an investigator to stake out your house for a few days to check on your activities. If the insurer wants a “sure thing” they will set up the infamous “independent medical evaluation” (a.k.a., a defense examination) whereupon you will be followed by the insurer to the examiner’s office and on the return trip. As part of the common surveillance, you may receive phone calls to your home with the investigator hanging up if you answer. (Cute)
4. Home Interview. This one is fully within the control of the claimant. Do not ever let these people in your home. They will pretend to be friendly and snoop about looking for anything of note such as general cleanliness or your ability to make yourself comfortable to hold against you in their report. If the interview turns unpleasant, the interviewer may produce video surveillance of you performing.
Scott B. Elkind is a Principal with Elkind & Shea, The Disability Benefits Law Firm. His practice focuses exclusively on disability benefits.
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