Person in Wheelchair

Denied Disability Insurance Claims

MY INSURANCE COMPANY DENIED MY CLAIM FOR LONG TERM DISABILITY INSURANCE.  SHOULD I APPEAL IT INTERNALLY?

This is a question that I receive quite often.  You’ve applied for long term disability insurance and your insurer has denied your claim.  Or, you were receiving long term disability insurance and your insurer has terminated your benefits.  Either way, you should have received a letter from the insurer advising you of its decision.  Invariably, the insurer advises you that if you disagree with its decision you may appeal it to their appeal panel.  It often gives you a certain period of time to do so.

The question I receive is, should I appeal that decision to the appeal panel?  Often this seems like an attractive option to my clients for a number of reasons:

  1. You may have been dealing with a pleasant claims representative who seems to be on your side;
  2. You know how sick you are and believe that there must be some mistake that can be easily rectified; and
  3. You want to have this mistake corrected quickly and hiring a lawyer and litigating your claim will be lengthy, intimidating and expensive.

To cut to the chase, I almost always advise clients or potential clients not to appeal the insurance company’s decision internally.  There are a number of considerations that go into that advice.

First, the reason for the denial or termination must be examined.  If it is a technical denial (ie. coverage was not in place or there was a pre-existing condition clause in play), there is no point in appealing internally.  These are questions of law or mixed fact and law and any appeal panel is not likely to see things a different way.  A Judge might.  You are better to file a statement of claim against the insurer.

If the reason for the denial is that the medical information available does not or no longer supports that you are totally disabled, you will be tempted to run out to your doctors and get further information.  Your denial letter may encourage you to do so.  However, almost always, the insurance company has enough supporting medical information on its file to continue paying or to approve your claim.  It has chosen not to and having your medical providers reiterate what they have already told the insurer will not result in an appeal panel over-turning the decision.  

However, if there is truly medical information that is new (ie. from a different doctor or specialist or a new diagnosis) or that the insurer does not have (ie. your doctor did not respond to requests for information from the insurer) then you may want to appeal this decision internally.  In my experience, that is the only time that appeals internally have been successful.

Second, you need to consider who is hearing your appeal.  While it varies from company to company, often the appeal panel consists of three individuals.  Often, one of these is the very claims manager who already denied your claim.  What are the chances that, barring truly new medical information, they are going to change their mind?  Not great.  Other members of the appeal panel may be a supervisor (who used to be a claims manager) and, perhaps, a medical provider who works closely with the insurance company either in its rehabilitative section or in providing medical advice to the insurer.  In other words, your appeal will not be heard by an unbiased and neutral panel.

Third, pragmatically, the result of appealing once or multiple times is often that it delays the inevitable – that is, that you need to sue your insurer.  After going through appeals for several months or a year or more, your financial situation is likely going to be further eroded, meaning that by the time you come to the realization that you need to sue the insurer, you are in desperate financial circumstances.  That is not a good way to begin litigation against a party who has significantly more financial resources than you.

Litigating quickly has some advantages.  It may, in the long run, actually save time. You take the insurance company out of its element (the internal appeal process) and into ours – the Court system.  The insurer may have information it has not shared with you (such as surveillance or a paper review of your medical file by another doctor).  The litigation process provides that the insurer must provide all of this information to you, so you know the case you need to establish to be successful.  Finally, client tell me that it is a relief to be able to offload some of the stress they are feeling onto us.  The appreciate having someone with experience in their corner.

So, in short, except for very limited circumstances, my advice is to retain counsel and ignore the internal review process offered by the insurer.  It will save time in the long run.

Lawyers Play A Must See

Check out the following event!!

The Royal Manitoba Theatre Centre and the Manitoba Bar Association
present the 25th annual Lawyers Play

Reginald Rose’s Emmy Award-winning classic drama

TWELVE ANGRY JURORS
Adapted by Sherman Sergel
Directed by Heidi Malazdrewich*

May 3–6, 2017

TICKETS NOW ON SALE

May 3 & 4 – $75 (includes complimentary wine and $55 charitable tax receipt)

May 5 & 6 – $100 (includes complimentary wine, post-show reception and $70 charitable tax receipt)

 

Online: Click here 

Phone: 204-942-6537, 12pm – 8:30pm, Mon-Sat

In person: Royal MTC Box Office, 174 Market Avenue, 12pm – 8:30pm, Mon-Sat

On a hot summer day after a long trial, a jury must decide whether a 19-year-old man is guilty of murdering his father. It looks like an open-and-shut case – until one juror begins to open the eyes of the other 11. Tempers flare as the evidence is re-examined and new uncertainties come to light, forcing everyone to truly question if there is in fact some measure of “reasonable doubt.” Twelve Angry Jurors is a heightened courtroom thriller that puts you on the edge of your seat while powerfully exploring what it means to live in a democracy.

Produced by special arrangement with the DRAMATIC PUBLISHING COMPANY of Woodstock, Illinois.

The cast of the 2017 Royal MTC/MBA Lawyers Play –
12 Angry Jurors: 
Zilla Jones (Foreman), Steve Scarfone (Juror Two), Jeff Hirsch (Juror Three), Cynthia Hiebert-Simkin (Juror Four), Heather Wadsworth (Juror Five), Sandi Phillips (Juror Six), Victoria Perrie (Juror Seven), John Harvie (Juror Eight), Tony Kavanagh (Juror Nine), Kalyn Bomback (Juror Ten), Bill Haight (Juror Eleven), Jody Ostapiw (Juror Twelve), Peter Kingsley (Guard).

Special guest actors performing the role of “The Judge”

Wed, May 3  Bryan Klein
Thu, May 4  Jim McLandress
Fri, May 5    Murray Sinclair
Sat, May 6   Gail Asper

About the Project

The annual Lawyers Play is one of Royal MTC’s largest fundraisers and, since its inception in 1990, has raised over $1,000,000 to help make live theatre accessible to all Manitobans. This production is a unique opportunity for members of the Manitoba Bar Association to work with theatre professionals and have a great time with friends and colleagues from the legal community.

For information on event sponsorship and advertising, please contact:
Melissa Novecosky, Special & Donor Events Coordinator
P: 204 954 6410
E: mnovecosky@royalmtc.ca

*The participation of this Artist is arranged by permission of Canadian Actors’ Equity Association under the provisions of the DanceOperaTheatre Policy.


Hiring The Right Personal Injury Lawyer

Choosing a personal injury attorney who actively investigates and maintains your claim and legal rights is vital in obtaining the payment that you’re entitled. So, how can you select the right one? Listed below are five recommendations that will help:

1. Experience. Never underestimate the value of an attorney’s knowledge in regards to evaluating and analyzing a case. Selecting a personal injury lawyer who knows things to seek out, where you can look for it – and knows what it indicates to your situation – can make all the difference.

Like, every province has certain regulations or standards linked to statutes of limitation, negligence, causation, contributory negligence, assumption of the chance among others that will be highly relevant to your case.

A part of that information and knowledge also requires choosing the proper place for your situation as that can affect how much compensation you get. While it’s clear a slide and slip scenario will be filed where the incident happened, not all injury incidents are that clearcut. For instance, if you’re hurt with a solution at home that has been stated in another province, the difficulties linked to where to create the fit might be challenging and must be examined to best protect your interests.

Selecting a personal injury without knowledge may imply that you are rolling the chop and taking a chance you simply must not be taking. So, before selecting legal counsel, inquire further about related circumstances they have managed, their success rates and whether they are ready to consider the event to trial if needed.

2. Target. The focus of an attorney’s exercise could make an enormous difference in the outcome of your case. A personal injury lawyer has special abilities when it comes to deciding problems of responsibility for example neglect and causation – and it is probably better prepared when it comes to properly valuing the payment for which you are entitled.

Approximately 95% of accidental injury lawsuits settle before trial, so knowing how to negotiate a good and realistic arrangement is vital as many factors are participating. This is definitely not the time to use your Dad “Billy Bob” the property lawyer – irrespective of how great he could be.

3. Name. Legal counsel’s name may move quite a distance when it comes to handling your event quickly and fairly because of the past negotiations with insurance providers and other attorneys in the region and in the court system(s) where they practice.

An attorney’s reputation provides that additional value since it may precede her or him – not simply from a plaintiff’s viewpoint, but in the defendant’s perspective as well as the court’s perspective for handling cases and doing things the proper way. It sets a consumer within the best situation to recover around they deserve as a result of what happened for them.

4. Objectivity. Objectivity cannot be understated in regards to being paid to your injuries. Ensure that your lawyer is objective and isn’t planning to settle your case prematurely as a way to move on to another client.

5. Character. The most overlooked factor in choosing an attorney is character. Although you might not be discussing your event together over dinner each night, once you’ve been hurt the past thing you need is an attorney who is not planning to be there for you to ask questions, give you a status on your own case or return your calls in an acceptable time.

Selecting a personal injury attorney to help you with an insurance state or suit could move a long way towards getting the money you deserve. When you feel the hiring process, remember, that you don’t need to speed. Make sure you’re confident with your lawyer’s honesty and expertise, and feel free to speak with numerous attorneys before choosing the right one for you. Picking your lawyer can be an essential step, and you will take some time to complete it right to be able to obtain the right attorney for your case.