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Keeping Your Disability Benefits

What should I be looking for? What should I do?

This is how insurance companies make money off disabled people. They have actuaries who study the chances of your becoming disabled and calculate premiums accordingly. By the odds alone, the premiums invested will yield a profit. When the insurer refuses to pay legitimate claims, their profits skyrocket. Its as simple as that.

Even when an insurer pays a disability claim, they can later change their mind because the profit incentive remains the same. We have handled many claims where the insurer terminated benefits after several years of payment. In one case benefits had been paid for over a decade and then were stopped despite no improvement in the claimant's condition. The insurer simply manufactured their own self-serving set of facts to support their case for denial.

Do you have a government disability case? Here's what you should be looking for.

Here are several ways in which insurers will set up a claimant for termination.

1. Unending Documents and Form Requests

The claims representative will start making repeated requests for documentation concerning your disability in an effort to "update" your file. In reality, your claim has been selected for possible termination and the insurer is fishing through the paperwork for any possible reason to deny the claim. Many times, a nurse reviewer will prepare a summary of medical documentation for presentation to an "independent" medical consultant. You need not worry about what it says as it will be all bad for you. The insurer is not going to go to such trouble to create a document which will not be to its own financial benefit.

2. Video Surveillance

The insurer will hire a private detective agency to undertake a few days of video surveillance. Either before or after the surveillance is completed, you will receive a "Daily Activities Questionnaire" to complete. This information will be used against you if your activities do not exactly match what is seen on the video surveillance. The only tip-off you may get will be phone calls asking for you with hang-ups once you answer as the detective will be verifying that you are home.

The claims representative will also have called you earlier and asked you when your next medical appointment is, or, worse, has scheduled an "independent" medical examination for you. Either way, you will be followed to the appointment and videotaped. They will make the appointment just prior to lunch time, hoping you will stop to eat or shop on the way home.

We had a client whose husband was observant and discovered the private detective. The husband would go out at night with a flashlight and shine it on the snoop, call the police on him for "casing the neighborhood," and, the best, drive quickly from the home to work while making furtive movements. Once he arrived at work, he would show the detective that his wife was not in the car........funny stuff.

3. The In-Home Interview

This in-home interview is arranged by a "representative" of the insurance company. Usually this representative comes from an investigative unit whose sole purpose is sniffing around for claims to deny.

The claims representative will just "happen to be in your area" and attempt to set up an appointment in your home. This is a lie. Your claim has been specifically chosen for a possible denial and they're just trying to surprise you and gather information.

The interview will start with the customary fishing expedition. The insurer will have gathered all recent medical records and all completed daily activities forms and slowly interrogate you about everything in an attempt to prove that, somehow, you are inconsistent in your representations. In some cases, the insurer will have undertaken video surveillance and will bring it on DVD to confront you and make you "admit" that you are participating in activities beyond those reflected in your daily activities report.

No matter what, never allow these people in your home! Nothing good can come of this. If you must meet with the person, we always recommend doing so in an attorney's office as it intimidates the claims people and restricts their time for inquiry as the attorney is on the clock or, if like us, not very accommodating. In the past, we have set up a videotape camera on a tripod to make sure that no misrepresentations could be made following the interview.

4. Insurer Referral For Social Security Disability Representation

We can never say this enough: being represented by someone referred by a Social Security claim representative is like playing with fire. First, this representative may not be an attorney (see explanation why this is undesirable in the Questions to Ask Before Hiring A Disability Benefits Attorney Section). Second, this representative has an immediate conflict of interest: Does he/she have a greater interest in acquiring your Social Security Disability Benefits or insuring the flow of new clients from the insurer? The referred representative is responsible for reporting back to the insurance company. This includes any evidence gathered which may not be favorable to your private long term disability claim. In the end, the business interest in maintaining referrals can lead the representative to report unfavorable information to the insurer leading to your claim denial and loss of representation for your Social Security case. Do not bother asking for advice from this referred representative as to what to do with the private insurer as they will feign a lack of knowledge in this area immediately or state that they do not represent clients against the insurer.......Big Surprise!

What should I do?
You can try to handle it yourself. Obviously, you have experience in these things and will know the insurer's tactics and tricks.........OBVIOUSLY NOT!

If you do not cooperate, your benefits will be terminated. If you cooperate, there is a very good chance that your benefits will be terminated. Either way your are involved in the proverbial "between a rock and a hard place" or "between the devil and the deep blue sea." What do you do now?????

You need to get representation immediately.

If the insurer realizes that you are being represented by an attorney whose skills at handling disability benefit claims are well-known, they will be less likely to engage in nonsense. As with any predatory animal, the insurer is attempting to pick off the weak from the herd. If you are represented by skilled counsel who assists in developing additional documentation demonstrating your continuing disability, it is likely that the insurer will back off and pick on a person who does not have aggressive representation. These unrepresented people will make all the expected mistakes and allow the insurer to manufacture an easy claim denial. For the insurer, picking on these folks is just like "shooting fish in a barrel."

In the immortal words of Ann Landers: "No one can take advantage of you without your permission." Do not become another "insurance company victim." Be aware that there are reasons for the inquiries made by the insurance company and these questions do not bode well for you.

In the end, you need to remember our firm's own quote concerning insurer claims behavior: "It is not about what is black and white, but rather what is green."

In simple Watergate terms, you need to "follow the money" and you will immediately come to the simple conclusion that the insurer only benefits by denying your claim.

If you want to keep receiving benefits, you should always consider hiring a counsel who is experienced in maintaining benefits for clients. This is an area in which Elkind & Shea has been very successful. We encourage you to speak to us at no charge to explore the possibility of protecting your rights. In the end, the small sum paid for competent representation is worth the sleep you won't lose by either worrying about termination of your disability claim, or, even worse, dealing with the actual denial of your claim.
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