Whether you’ve just filed a long-term disability claim, or you’ve been on claim for years, chances are sooner or later you’re going to have to talk to an insurance claims adjuster, who will be responsible for approving or denying your claim.
Insurance adjusters (often also referred to as claims handlers or claims analysts) are a necessary part of the disability claims process. They help the insurance company evaluate claims and identify potential cases of fraud. But they don’t always make the right decisions, and they’re not necessarily looking out for your best interest. Insurance adjusters can and do deny or terminate benefits, even in cases when claimants are legitimately disabled.
In this blog post, we’ll provide some clarity on an adjuster’s role and tips on how to deal with them. Please note that while insurance adjusters work with many different types of insurance claims (such as a car accident, property damage, etc.), this post and our work focuses on disability insurance claims.
What Does a Disability Insurance Claims Adjuster Do?
A long-term disability insurance adjuster is responsible for evaluating and processing long-term disability insurance claims. Some common duties of an adjuster include:
- Reviewing claim applications and determining if you meet the policy definitions for disability. This usually involves reviewing medical records, doctor statements, and vocational assessments.
- Determining the date of disability onset and if/when you can return to work.
- Calculating the amount of the monthly disability benefit you are eligible for based on the policy terms and your pre-disability income.
- Periodically reviewing claims after initial approval. Typically, this means they’ll request new documents and evidence from you that proves you’re still disabled (according to the definition of disability in your insurance policy).
The insurance adjuster may communicate with you over the phone or email. However, they might also request a “field interview” in your home or at a neutral location. Ideally you should politely decline this request, but your plan documents may require one. Be sure to read carefully.
RELATED: Should I Meet With a Disability Insurance Representative? – Bryant Legal Group (bryantlg.com)
Why You Need to Be Careful When Dealing With the Insurance Claims Adjuster
As noted above, the insurance adjuster is a necessary part of the overall process. But they aren’t your friend and they aren’t looking out for your best interests. They are an agent of the insurance carrier. Their job, in a nutshell, is to save the carrier money. They are instructed to look carefully and dig deep for any evidence that you aren’t really disabled, or that your pre-injury income is lower than you say. Sometimes, this can lead to biased decision-making—or in some cases, outright illegal tactics.
For example, about 20 years ago, insurance company giant Unum was caught illegally denying and terminating expensive “closed-block” insurance claims they were no longer offering but were obligated to continue paying to on-claim beneficiaries. They also have a history (through the present day) of tying adjuster and director compensation to company profitability. This creates a clear financial conflict of interest and incentivizes unfair claim denials. And Unum is certainly not the only insurance company using sketchy tactics.
RELATED: UNUM’s Dirty Tricks: Tying Compensation to Denied Claims – Bryant Legal Group (bryantlg.com)
So, you need to be very careful about what you say, and how you say it, when you’re talking with an insurance adjuster about your disability insurance claim. They will probably be very nice and sound very understanding. But they do not have the same goal as you do.
8 Tips For Talking With the Disability Claims Adjuster
Be organized and prepared
It may be helpful to have relevant medical records, doctor’s notes, list of medications, pay stubs, and other medical and financial evidence on hand for you to reference. Be thoroughly familiar with your diagnosis, treatment plan, and limitations. If the adjuster asks you a question and you say something that isn’t true, or forget important information, it could jeopardize your claim.
Stick to facts that are relevant to your claim
Don’t volunteer information about your personal plans and hobbies, whether or not you were satisfied with your job, or whether things are stressing you out at home. Stick to your disability and how it affects your work. Information that isn’t relevant to your claim will never, ever help your case. And depending on what you tell the adjuster, they may suspect you’re using your disability as an excuse to, say, go on vacation, get out of a crummy job, address personal concerns, etc.
Know your facts
Be prepared to talk about how and why your disability prevents you from working. Avoid vague and general statements like “I’m too tired to concentrate” or “I can’t sit for very long.” Use specific details, estimates of amounts of time, and examples of how your symptoms make important job tasks impossible.
Remain calm
These can be stressful conversations, particularly if you’re feeling frustrated, confused, overwhelmed, or you just don’t agree with what the adjuster is telling you. Stay calm, focused, and provide direct answers when asked—even if you feel like you’ve been answering the same question over and over again. If you start to get confused during a call with an adjuster, explain that and ask that any remaining questions be forwarded in writing so that you can forward complete and correct responses. If you blow up, you might say something you’ll regret—and the adjuster may be more motivated to deny your claim. Or if you are confused and just trying to get through the call, you risk giving incorrect or confusing information—that the adjuster may use to deny your claim. (We wish this weren’t the case, but human beings aren’t always neutral decision makers.)
Don’t exaggerate
The worst thing you can do in any insurance claim is lose your credibility. Always be honest and truthful with the adjuster. If they suspect you are stretching the truth, they will work hard to find the evidence that proves it.
Take notes
It can be extremely helpful to take notes (or have a loved one do it for you) while speaking with the adjuster. Write down important names, dates, and details that were discussed so you don’t forget them.
Ask questions
If you don’t understand something and need clarification, ask the insurance adjuster to explain. If you don’t agree with an adjuster’s decision, ask them how they arrived at their conclusion and what evidence they are basing it on. Be sure to get a copy of the adjuster’s written decision. Be kind and respectful, but insist on clarity and don’t be afraid to advocate for yourself.
Ask for requests in writing
If the claims adjuster asks you for additional information or documentation in person or over the phone conversation, ask them to email you so that you have a written record of the request. This helps prevent any misunderstandings or disagreements about what was actually requested. It also helps ensure that you collect and submit the necessary documentation to get your claim approved.
How a Long-Term Disability Attorney Can Help
One of the best ways you can protect yourself from preventable mistakes and/or unfair, unreasonable insurance adjusters is by contacting an experienced long-term disability attorney.
Disability insurance plans are complex and confusing by design. Claimants often don’t fully understand what their policy does and does not cover, and don’t always have the knowledge or experience to push back when the claims adjuster makes an unfair decision.
Your long-term disability attorney can help in many key ways. For example, they can:
- Review your policy and plan documents to ensure the insurance company is acting in accordance with your policy terms and relevant regulations. They can identify any violations or errors.
- Handle communication and negotiations with the adjuster directly on your behalf so that you don’t have to.
- Help you prepare for (and attend) any field interviews that your plan might require.
- Gather and prepare the documents you’ll need to prove your claim, such as medical records, physician statements, vocational assessments, and financial records. They may even consult directly with medical experts (with your consent) and family members to get the necessary evidence.
- Advise you on steps you can take to strengthen your claim, such as making sure you’re receiving medical treatment, following doctor’s orders, and keeping good records.
- Advocate for you throughout the process to ensure the adjuster is properly evaluating your disabilities and limitations.
- Take the insurer to court on your behalf if needed to resolve a claim dispute.
When Should I Contact a Long-Term Disability Attorney?
The ideal time to contact an attorney is right away, before you submit your claim or submit additional evidence while your claim is being reviewed. Getting legal input at the start of the process can help everything go more smoothly and improve your chances of a timely approval.
However, if your claim has already been denied or your benefits have been terminated, it’s particularly crucial that you speak with an attorney as soon as possible. Most long-term disability policies are governed by ERISA, which imposes strict deadlines and limitations in the appeal process. If you don’t supply the right evidence during your administrative appeal, you won’t be able to add it later if you need to sue the insurance carrier.
At this point, very simple mistakes or oversights could jeopardize a lifetime worth of disability benefits, potentially with no recourse. Is the risk worth it? We don’t think so.
At Bryant Legal Group, we focus on helping disabled people obtain and keep the disability benefits they deserve, so they can continue to live their best possible lives. To schedule your free consultation, call us at 312-586-9128 or complete our online form today.