What should I know before I submit a disability claim in California?

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Terrence J. Coleman - Insurance Coverage - Super Lawyers

Answered by: Terrence J. Coleman

Located in San Francisco, CAPillsbury & Coleman, LLP

San Francisco, CA
Phone: 844-785-3416
Fax: 415-433-4816

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When it comes to submitting a disability insurance claim, there are three key points to keep in mind. One, develop a strong relationship with your treating physician. Two, pay attention to the details of your particular policy. Three, take great care before you provide anything in writing. Let’s look at these three points in more detail.

1. Your Relationship With Your Doctor 

If you don’t have a strongly supportive treating physician, your disability claim is unlikely to succeed. The insurance company has a battalion of doctors on staff who will scrutinize every aspect of your claim. You need the support of your own physician to combat the other doctors who are not on your side. 

You also need to maintain a consistent track record of seeing your doctor and ensure that your problems are recorded in detail. Many people get into the habit of speaking to their physicians in shorthand. For instance, your doctor might ask, “How are you today?” and you might reply, “I’m okay.” You mean that your disabling condition is the same as it was last week – no better and no worse – but that’s not how your insurance company will interpret it. Without contemporaneous evidence, your insurance company is very likely to see “I’m okay” in your records and immediately reject your claim, asserting that you yourself said that you were perfectly fine and not disabled at all. 

At Pillsbury & Coleman, LLP, we go out and obtain our clients’ medical records for them. If something needs to be clarified in the medical records, the time to do it is before the claim is submitted, not after. We also encourage our clients to be open and honest with their doctors. It’s not whining and complaining, it’s providing detailed documentation that will stand them in good stead later.

2. Your Insurance Policy

Do you have a detailed understanding of what your policy provides? No two insurance policies are necessarily alike. Often, the definition of a “disability” differs from one to another. Under some policies, you are considered disabled if you can’t perform your current job. Under other policies, you are considered disabled only if you can’t perform any type of job at all.

You also need to know how long your benefits will last. Some policies provide benefits for a lifetime if you are disabled in an accident, but they only provide benefits until age 65 if you are disabled due to illness or disease. So what happens if you injured your back in a car accident years ago, and the pain has slowly progressed until you can no longer work? Your insurance company may have marked your file for closure at age 65, saying that your disability is due to degenerative disc disease. However, the truth is that the car crash is what started it all, so you may actually deserve lifelong benefits.

At our firm, we have a detailed understanding of California’s “process of nature” rule and how it affects claims. In short, we have been able to help numerous dentists, lawyers and other clients obtain lifetime benefits instead of limited benefits under this rule.

3. Your Written Communication

It’s wise to never submit a written claim form without having a specialist review it first. These forms are cleverly drafted by the insurance company and contain hidden traps. For example, have you ever wondered why the form provides such a tiny little box for you to explain how you became disabled? With such a limited space to tell your story, you are more likely to write something brief that the insurance company can twist to its own advantage. You don’t have to fall for such traps, however. It’s possible to simply write “See attached” in that little box and provide a separate document that details your condition.

At Pillsbury & Coleman, LLP, we share numerous tips like this with our clients. Our goal is to help our clients submit the strongest claims possible and ultimately obtain the benefits they deserve.

Disclaimer: The answer is intended to be for informational purposes only. It should not be relied on as legal advice, nor construed as a form of attorney-client relationship.

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