How the Insurer Will Investigate Your ERISA Insurance Claim

Posted on September 29, 2018 by cjblog

If you are disabled and need to apply for ERISA insurance benefits, you should know that the insurance company will thoroughly investigate your claim. You will have to comply with the plan administrator’s requests for information regarding your medical condition, work background, and functional abilities.

It's important to work with a skilled attorney who will review your situation and help you through the process. Call CJ Henry Law Firm today to find out more about your claim.

What Happens When You Apply for ERISA Disability Insurance?

The goal of any insurance company is to minimize or quickly deny claims so that they do not have to pay out as much money. Thus, you should work with an attorney who can help you correspond with the ERISA insurance company and provide necessary information for your claim.

You Must Complete Forms and Questionnaires

Disability claims often involve a ton of paperwork. When you apply for ERISA insurance, you and your doctor, as well as your employer, will have to complete several forms. You may also be provided with questionnaires from the insurance company to supplement the information you submit. Forms may ask questions about the following:

  • Your illness, injury, or other medical conditions
  • The severity of your symptoms
  • Your doctors and other medical providers
  • Medical treatment that you’ve received
  • Prescription and OTC medications
  • Prior and current job duties and responsibilities
  • Activities of daily living
  • Hobbies and daily activities

You must give accurate information to the ERISA insurance company. You should not overstate or minimize symptoms of your condition. The insurance company will review your forms and compare information that they obtain from medical records for accuracy. If they suspect that any information you provide is not accurate, then your claim may be denied.

They Will Review Your Medical Records

In order to win an ERISA insurance claim, you need to submit medical evidence. The insurance company won't approve your claim if you only base it on your description of your symptoms

The insurance company will want to review medical records from all of your treating providers. They may have specific forms for your doctors, or you may have to sign a release so they can request all records between certain dates. The insurance company will review your records as they look for evidence of your disability. They will prioritize information from medical exams and objective, fact-based information, such as MRIs and X-rays. They will give less attention to subjective claims you made in your medical records because they will have already obtained that information in prior forms.

You May Have to Attend an Independent Medical Examination

The insurance company may also ask you to attend an independent medical examination (IME) by a doctor of their choosing. This is often called a functional capacity evaluation (FCE). The insurance company will pay for these exams. The goal will be to get an outside opinion about the status of your disability.

An IME typically takes around an hour to complete. The IME doctor will have reviewed all of your medical records, and they will ask you questions about your functional ability.

Be honest about all of your conditions with the IME doctor so that they get an accurate view of your disability. Don't exaggerate, since the examiner will likely make note of any exaggeration in the report. But at the same time, don't minimize your symptoms, either. If you make it sound like your symptoms aren't that bad, the doctor may feel that you are able to return to work.

The doctor will issue a report after the exam that discusses your symptoms and diagnosis. It will also address opinions in your medical records.

Vocational Analysis of the ERISA Insurance Company

The insurance company will also perform a vocational analysis where it reviews your past and current work and determines if you are able to complete the duties and responsibilities. The insurance company may determine that you are unable to complete your own occupation or all occupations:

  • Own Occupation: Your medical condition prevents you from doing your job in your own occupation.
  • Any Occupation: Your medical condition prevents you from doing any job in any occupation.

You should review your Summary Plan Description (SPD) to determine when your ERISA insurance benefits will apply.

We Can Help With Your ERISA Insurance Claim

It's difficult to manage a claim on your own. Work with an ERISA insurance lawyer who can guide you through the process and advise you of your options. Call CJ Henry Law Firm today.

This entry was posted in Blog by cjblog.