Insurance Company Manipulation of Herniated and Degenerative Disc Claims

A variety of degenerative back conditions affect many people. These symptoms can be exacerbated by certain professions and activities, making it almost impossible to work. Many doctors, including radiologists and interventional cardiologists, can suffer from back injuries or herniated disks due to heavy lead aprons. There are many types of surgery that can help alleviate symptoms such as discectomies or insertion of rods or pins. However, not all surgeries work. Patients can experience numbness, weakness, or loss of sensation in their extremities, even before and after these surgeries. Many people choose to quit their jobs and apply for disability insurance benefits when the condition becomes unbearable. It is not always as easy or straightforward as you might think. These are just a few of the ways that insurance companies can defend against claims to delay payments or deny benefits.

Using a reduced version of the occupation

Many professionals can help with back problems. People may attempt to continue working as they get worse by shifting their job responsibilities and trying to swap more physically demanding tasks for other aspects until they are unable to work anymore. The insurance company will examine the occupation duties and responsibilities that were performed on the date of the disability. This date is often equated with the date they stopped working, rather than when they became disabled. However, this may not be as early as it seems. Some insurance companies won’t allow an insured to claim a disability date until they have determined that the individual is unable work. The insurance company will not consider the changes in work duties or responsibilities that result from the disability when evaluating the claim. Instead, claims are denied if the insured can perform the reduced occupation.

This can be avoided by insisting on a precise date of disability. Also, you should see a doctor as soon as possible if you are unable to work as hard or as often as before. Many people work hard and don’t want to quit their jobs. However, it is important to be prepared and cautious to ensure you receive your disability benefits.

Enforcing stringent care & treatment requirements

People prefer not to have surgery, or any other invasive procedure for an injury or condition that isn’t life-threatening. Insurance companies use this fear and trepidation to turn it into an excuse to deny your claim. Insurance companies can make the assumption that an insured cannot work or is unwilling to take on more risky procedures. This can lead to denial of the claim and the inability to receive benefits. This is why it is important to discuss, document, and communicate with your doctor any recommended treatment options, no matter if they are conservative or surgical.

The “Good Day–Bad Day” Argument

Many people with chronic back pain know that there are good and bad days. Insurance companies love to monitor insureds and to investigate their activities. After surveillance has been obtained, the investigators will cherry-pick the data and possibly misunderstand the capabilities of the insured. Private investigators will often refuse to pay disability benefits if they see an insured grocery shopping or driving to work. Even if an individual feels good for a day, or does something that causes pain later on, it is important to be aware of the information reported on the monthly claim forms. Pay attention to your surroundings and any suspicious people or persons that may be around you. You should also be careful about what you can or cannot claim and any actions that caused pain.

Changing the Disability from Total to Remaining

This strategy can be both beneficial to the insurance company and detrimental to the insured. Many policies that cover disability only provide complete disability benefits. If the insured is not deemed completely disabled, claims are denied. The issue may be more complex for policies with both total and residual coverage. If the instructions and documents are not followed, insurance companies can deny or delay claims for residual disability benefits. Insureds do not receive a guaranteed amount of benefits every month. This can cause more anxiety and stress. Insurance companies might even attempt to profit from that anxiety by offering to settle residual cases for pennies per dollar less than what they have already reserved.

Business reasons may also justify defining claims as total rather than residual. The total amount of total disability benefits is kept as a reserve. This expense is recorded as an expense. A residual claim is only one-third of the total amount. This is because the claim may not be paid every month. A company can reduce its reserves and associated expenses by reclassifying claims from total-to-residual, which helps to lower the loss ratio and increase income and meets management performance goals.

These are just a few of the many tactics and strategies that disability insurance companies use to deny legitimate claims and protect their bottom lines. These could all be a book in themselves to share the horror stories and experiences we’ve heard from clients and other professionals.

These tactics may sound familiar, or you’d like to learn more about how to navigate the complex waters of disability insurance, contact our offices at (855)828-4100, or visit our website, Royal Claims Advocates.