Who can help me with disability insurance claims?

April 9, 2012 12:48 PM

I’m looking for advice on dealing with with employer provided disability insurance. I’m out of work due to illness, and I am having trouble navigating the disability insurance provided by my employer. Do I hire a lawyer? Are there other people that I can hire to help on my behalf?

I’m in Wisconsin, if that helps. I tried googling this question, and I am finding both advocates and lawyers, and advocates that are lawyers but not which I should choose or how to choose one. I know WOM recommendations are the best, but I don’t know anyone that’s gone through this so I have no one to turn to for recommendations.

I went on medical leave this past fall. My work provided disability insurance, but navigating it has been a challenge, because my doctors are still investigating the cause so have no information on when I’ll “be better”. I was told that it takes 7-10 days to process a claim, but with follow up medical records, it took three months to receive roughly 6 weeks disability pay, which did not actually cover all the time I was out of work at that time.

Much back and forth and misinformation from the insurance company as to what I needed to provide them, they reopened my claim 2 months after my last payout. Their review of it is still pending.

Part of the problem is that the doctors are still investigating the cause of my illness, and because they don’t know what is wrong, they can’t say when I’ll be well enough to go back to work. After talking to the person at the disability insurance company working on my case, she said that without a return to work date, the best they can do is pay retroactively for the time out of work, after reviewing doctor records. BUT if I send the records too soon after they got the previous records, it extends the time for review, i.e. extending the time until I see any payment.

Add to the fact that last time my doctors office sent over records it took 8 days from the time they sent digital records from the local office to the copying service to mail them out, then another 15 days for the disability insurance company to receive them via postal mail.

This is all the quick version, there is much I left out, but what I desperately need to know is how to navigate the system or who could help me. Is there some profession out there to help me speed things up and smooth out the bumps while knowing when they’re getting the runaround? On top of everything else, I’m just too tired most days to harass whomever needs harassing to get this done.

If I need a lawyer, how do I find one? Should I get a recommendation from a generalist, or find a lawyer that specialises in disability? Or is there another profession that helps in cases like these?

(And if you have a specific reference for someone you would recommend, please include!)

posted by [insert clever name here] to Health & Fitness (7 answers total)

I think this is more of a time to talk to HR than it is to talk to a lawyer. You're trying to navigate insurance purchased by your employer. It's part of your employer's job to help you figure that out.

Some people might recommend getting yourself what's called a "public adjuster." These are basically just people who interface with insurers to try to get you all the benefits to which you are entitled. Which sounds great, only most insurers and attorneys--plaintiff and defense--don't particularly like them, as they tend to add a layer of complication to the situation that's rarely helpful. They're not lawyers and frequently don't understand insurance policies or the law all that well, so they very frequently wind up making demands for payment that are unjustified, landing their customers in litigation. For example, the appearance of a public adjuster on a property loss almost always signals that the insured is trying to use their insurance policy as a renovation and update fund rather than as insurance, i.e., to pay them for their actual loss. Adjusters actually have an incentive to encourage this, as if they only manage to get what the client could have gotten on their own, the client is pissed.

Personally? If you're not getting the love you need from your insurer, and your employer isn't helping, just go straight to a plaintiff's attorney. A decent one will want to get the thing settled without going to court, and they're going to be way better than you are at getting the paperwork done. Most good plaintiff's attorneys will have a graduated fee schedule, i.e., this much if we get paid without going to court, this much if we get paid without going to trial, this much if we have to to go trial, this much if we have to appeal, etc. Each successive level will represent a higher percentage of the total recovery. Again, hiring an attorney for this sort of thing 1) will not cost you money up front, and 2) does not automatically mean you're going to wind up in court. Anecdotally, the most successful plaintiff's firm in my part of my state settles upwards of 60-70% of its cases without ever filing suit.

As to how to find a lawyer? Look in the phone book. Most plaintiff's attorneys will take this type of case. Look for the people that say they do Social Security stuff. Contesting government benefits isn't all that different from contesting private benefits, when it comes right down to it.
posted by valkyryn at 1:07 PM on April 9, 2012

Response by poster: I've talked to HR, but that's some what of a dead end. I can't always reach the person I need to reach, that person doesn't always respond to email either. My employment is terminated currently due to this illness (FMLA protection ran out, but I am on good terms with them). When I have talked to HR, they have called the disability insurance company to find out what is going on, and that seemed to light a fire under them for a bit, but it's back to dragging on. Last time I was getting the run around no one could tell me what was going on, and then my employer's HR director called them and "oops" something was filed wrong on their (the insurances) end, which got things moving but now its back to a dead halt while its "in review".

I haven't been denied my claim, it just keeps hanging in limbo and its very hard for me to follow up. The person working on my claims has often failed to return my calls and only answers the phone about a quarter of the time. The rest go to voicemail. I've also tried their general line but that's where I've gotten the most wrong information and they have less access to my claim to give an accurate update of that status.

I feel a bit like an attorney is a nuclear option, and I'm not sold that is the direction I want to go yet, especially since my claim hasn't been denied. But being in limbo has essentially the same effect - I'm not getting paid and need my disability to help with living expenses and medical bills.
posted by [insert clever name here] at 1:50 PM on April 9, 2012

When you say that the doctors don't know the cause yet, is it potentially work-related? If so, you need to hire a workers' comp lawyer.
posted by amro at 2:15 PM on April 9, 2012

Response by poster: I don't want to derail with the medical details, but no, it is not work related.
posted by [insert clever name here] at 2:31 PM on April 9, 2012

I doubt if many insurers are going to make payments on an illness with an unknown etiology/diagnosis and no clear prognosis without substantial additional information. In the absence of a clearly defined injury/disability/impairment/disease it is predictable that an insurer is going to be hesitant--particularly since there is no reasonable means of recovering payments in the event the disability was not covered by the particular policy. I would think your best recourse is to work closely with your physician office and the account manager with the insurer.
posted by rmhsinc at 2:31 PM on April 9, 2012

Response by poster: rmhscinc, I think you hit the nail on the head as to why I need to find someone that understands how the system works to help me sort out what I need to do to get my claim through. My initial claim was approved, and I've only gotten worse so I assume (though perhaps incorrectly) that I am providing the right information.

The problem I'm having is what you are suggesting you do, working closely with the physicians' offices - which I've not had problems- and with the disability insurance company - which I have had a lot of problem with wrong information, them sitting on invoices, not getting call backs, sending the wrong info to my doctors office. And because I don't know the way these things work, all I can do is wait and hope the last thing they told me was correct. That is where I need help and I can't seem to get it directly from the disability insurance company.

I don't think the problem is the information I'm sending to the company - at the very least if it is, they're not telling me that. I'm just stuck in disability insurance claim limbo, and can't seem to navigate my way out of it. Part of the problem as well is that I have an omnipresent 'brain fog' that makes it hard for me to concentrate - dealing with the complexities of the insurance claim is increasingly difficult for me.
posted by [insert clever name here] at 3:31 PM on April 9, 2012

It sounds like more of a two-fold communication problem than a lack of coverage. I've also just started on Salary Continuance (Employer Disability, SC). In my company's case, there are internal case managers for normal medical leave but they don't handle the longer-term stuff. Also, HR will only advise on the processes going through sick leave to unpaid leave, etc.

The actual insurance is administered by an external entity (I couldn't even tell you it's name) but the process and communication is handled by a large, professional benefits management company. That's where my contact resides. He's helpful, if somewhat obtuse sometimes and it's taken some time to begin to understand the process leading to payment.

I can understand the challenge if you're dealing with "brain fog" at the same time. And some of the confusion might be simply the brain fog combined with Byzantine processes. Before engaging someone externally, why not ask a trusted friend or family member for support. Explain things as best you can and then include them on the next call with the insurer. Don't make it confrontational.

In my case, it took a while to understand that everything will be paid in arrears as a part of a very specific monthly process and I needed to be on unpaid leave first. So I'll be a month or more behind in any income for the foreseeable future.

Good luck to you.
posted by michswiss at 3:58 PM on April 9, 2012