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Hello, I’m back with more questions about how to handle a private disability claim. I’m helping a relative file for coverage under several private disability policies. Warning, even though I’m trying to make a very long story short it is still quite lengthy.
My relative has progressive memory loss/ brain damage that probably started in the late 1980s. In his case the damage is not straight across all skills (like a person who has mental retardation). So at times, and for short periods, he appears to be normal but in several areas he functions like a person with severe mental retardation. He is not able to handle complex tasks, learn & remember new skills, do higher level thinking, understand directions and other things needed to hold down a job.
In 1983 & 1985, when he was an trial attorney, my relative took out four disability insurance policies and they were all currently paid and in force when he stopped having the cognitive skills needed to be an attorney in 2001.
Even though he had ten years of college and several college degrees he wasn’t able to handle a “professional type job” anymore. He finally started working as a security guard. His income was significantly lower and he let one of the disability policies lapse about 2005.
By 2006 he was starting to have difficulty handling the duties and responsibilities of being a security guard. He had extensive medical testing due to these memory problems. Brain damage and memory loss was documented by several doctors with EEG and various other tests. Report was discussed verbally with him (former attorney, now security guard) and spouse but neither remember getting any copies of any of these reports. Both were in denial of how serious these problems really were.
2006/2007. He had cancer/surgery/chemotherapy and unable to work at all so went on disability for several months (premiums did not need to be paid while disabled) and was paid by the 3 policies he had left. Insurance company was told that he was a security guard.
2007 to 2010. Modifications and adaptations in hours/schedule and responsibilities made to his security guard job because he was having problems handling the work (problems learning new skills, using the computer, remembering what he was supposed to do).
November 30, 2010. He was totally unable to handle the responsibilities of security guard job and was fired.
December 2010 . He lost and “forgot” to mail a stack of bills probably due to his memory problems and let another “own occupation” disability policy lapse (remember he stopped being able to do his “own occupation” as an attorney 9 years earlier).
2011 & 2012. He was in and out of the hospital several times (even in a coma for ten days) but refused to accept that he had any problems. During this time several different doctors said in reports that he was totally disabled. Family was still in denial.
June 2012. Spouse finally realized that husband had disability policies and that several doctors over the past year said that he was unable to hold any job so she requested forms. Obviously the spouse should have been aware of the disability policies and checked on them but she was too busy holding down two jobs to support the family, caring for children and husband.
August 2012. Spouse found and looked at original disability insurance policies for the first time and realized that these were “own occupation” disability policies from when husband was an attorney. Husband had little memory of getting policies, did not realize that they were “own occupation” policies and only vaguely remembered paying for disability policies for years (29 years) probably due to his progressive brain damage. It is very difficult dealing with someone with memory loss as they don't realize that they have memory loss. Even now my relative can get quite angry if you even suggest that he has problems.
I discussed this with other family members and we don’t even know where to start. The person who sold him the policies is dead, the company has changed hands several times and it is a complex case.
Obviously it would be best for the family to receive payments for as far back as possible and since the policies lapsed after he was unable to be an attorney they feel that all four policies should be in effect (not just the two where premiums had been paid for all 29 years). It was suggested that I talk with someone at theinsurance company first on how to proceed.If you are familiar with disability insurance or insurancecompanies do you agree? Wouldn’t they just say “sorry, you are out of luck”, we will only pay from December 2010, or later, on the two policies (which wouldn’t be enough money for the family to pay their bills)? I would rather not start with an attorney (who will take 1/3 of the money as payment) unless I absolutely have to do that.
Help!
The family is in serious financial trouble and are in danger of losing their home.
Please help me know where to start so I don’t add to all of the mistakes that have been made previously. Feel free to PM me.
The first place to start is with a lawyer who specializes in this kind of thing. Like tomorrow.
Note that you probably don't have any legal status to do things for this relative - and that he may have to have a guardian appointed. Also - there may be statute of limitations issues here (as well as other legal issues). This certainly isn't anything anyone can help you with on line. Robyn
One issue you are going to have to overcome is pretty much every insurance policy has a clause about filing claims in a timely manner and 9+ years after the fact isn't going to meet anyone's definition of timely. I realize that they "forgot" but 6 months is forgetting, not 9+ years. I agree, seek out an attorney but I wouldn't hold out hopes of getting this done.
This is also a good example of why you need to have a central file for this kind of information and that you need to make sure your spouse knows about this as well at your children or some party that does not live in your home.
I used to write own occ policies as dictated by underwriters so I am wracking my brain for particulars. There is a lot involved here like time limit on claim submission date, proof of inability to preform own occ and probably more. I would first begin with the insurance company. Don't do it over the phone though. If at all possible, make an appointment with a representative from the company. Yours is a very complicated issue and even the claims adjusters or underwriters might be in a bind over how to help since the policy is so old.
Ultimately, if you wish to take it farther, it may involve your going to an attorney specializing in insurance matters. But I would first try and speak to the insurance company. You have nothing to lose and they may be able to help. I know how frustrating it can be to deal with them but you may get lucky and find someone who can guide you through this.
I had a very nice discussion with the claims agent and have spent the last few days gathering information, writing time lines and getting input from family members and other knowledgable people.
Although, I'm still overwhelmed I'm not OVERWHELMED!!!!!
I had a very nice discussion with the claims agent and have spent the last few days gathering information, writing time lines and getting input from family members and other knowledgable people.
Although, I'm still overwhelmed I'm not OVERWHELMED!!!!!
Good for you! That's the way to begin. Just take it one step at a time as you are doing and take deep breaths along the way. Best of luck to you.
Bear in mind that no one will be permitted to discuss anything with you, from the insurance side or the medical side, until and unless you are given power of attorney or you are otherwise named an authorized person to receive the information. The insurance company is not -allowed- to talk to you at all if your name isn't on a document stating that the patient wants them to talk to you. They're not even allowed to acknowledge that your relative was insured by them. It's part of HIPAA. Your ability to help will be pretty limited until you're an authorized person.
Bear in mind that no one will be permitted to discuss anything with you, from the insurance side or the medical side, until and unless you are given power of attorney or you are otherwise named an authorized person to receive the information. The insurance company is not -allowed- to talk to you at all if your name isn't on a document stating that the patient wants them to talk to you. They're not even allowed to acknowledge that your relative was insured by them. It's part of HIPAA. Your ability to help will be pretty limited until you're an authorized person.
Good luck!
That is true, but most insurance policies are "boiler plate" and the OP may be able to ask for nonspecifics of the provisions of the general policy. She may be able to recieve some helpful information there. Nothing to be lost by asking. Then when that has been exhausted she can go about seeking power of attorney or whatever legal means needed to seek information regarding her relatives specific policy.
Please bear in mind it is the insurance claim representative's responsibility and duty to explore every possibility why the claim should be denied or limited. No matter how congenial they are, they are always diligent in this regard. So it is possible, in the course of dialogue and submission of documentation, that you could be undermining your cause because you don't know the rules of the game. It's a fine line, and when in doubt, seek legal counsel. This does not necessarily mean you need to hire a attorney (although you may ultimately have to). It is possible to have a attorney "in the background" giving you guidance and direction (avoiding pitfalls, traps, etc.). I am a retired licensed California Insurance Adjuster. Good Luck.
Thank you to everyone who replied to my posts about disability insurance. Here is an update.
I had informal help from an attorney and a disability insurance agent on what to include in the private disability insurance claim. I also had help from several excellent writers to proof read everything and to make sure that it actually said what I intended it to say.
The whole process took longer than writing my thesis for my Masters Degree and is considerable longer and more well written than it was. LOL
The packet to the insurance company had 71 photocopied pages of medical records and 58 photocopied pages of forms and letters regarding SSD. The most important part was 37 pages of completed forms, attachments, letters from doctors, timelines and the letter of explanation. When, I finally mailed that 166 page packet I was very happy. Now all we need to do is wait.
If we don't get the response that we feel is fair and correct we will go to a disability insurance attorney at that time.
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