Help Making a Disability Claim
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Step-by-Step Guide to Making a Disability Insurance Claim
Becoming disabled and unable to work is a life-altering event. Filing a disability insurance claim can feel overwhelming when you are already dealing with health challenges and financial uncertainty. At Dorian Law, we aim to simplify this process and provide you with clear, compassionate guidance to help you file a disability claim effectively and minimize stress.
This page outlines the essential steps involved in making both group and individual disability insurance claims. While this information is designed to be helpful, remember that every claim is unique, and the specific requirements can vary depending on your policy and the insurance company. If you encounter obstacles, feel unsure about the process, or simply want experienced assistance to manage your claim from the outset Dorian Law is here to support you. We are committed to easing your burden and maximizing your chances of securing the disability benefits you deserve.
These six steps provide a general roadmap for filing a disability claim. Specific requirements may vary. Always refer to your specific policy documents and communicate directly with the insurance company or plan administrator for precise instructions.
Step 1
Understand Your Disability Insurance Coverage
Locate Your Policy Documents
Gather your disability insurance policy documents. For group policies, your employer's HR department can usually provide plan documents or direct you to where to find them (Summary Plan Description, Policy Booklet). For individual policies, locate your policy paperwork.
Identify Your Policy Type
Determine if you have group disability insurance through your employer or an individual policy you purchased yourself. This will impact the governing laws and claim procedures.
Carefully review your policy documents to understand:
Definition of Disability: "Own occupation" or "any occupation"? Is there a change in definition after a certain period?
Benefit Amount: What percentage of your income will be replaced? What are the maximum monthly benefits?
Elimination Period: How long must you be disabled before benefits begin?
Benefit Duration: How long can benefits be paid (e.g., short-term, long-term, to age 65, to SSNRA)?
Exclusions and Limitations: Are there any conditions or circumstances excluded from coverage or subject to limitations?
Claim Procedures: Does the policy outline specific steps or deadlines for filing a claim?
"Offsets" or Reductions: Are there provisions that reduce your benefits if you receive other income (like Social Security Disability)?
Step 2
Notify the Insurance Company or Plan Administrator Promptly
Contact the Right Party
For group policies, notify your employer's HR department or the designated plan administrator and the insurance company (if known). For individual policies, contact the insurance company directly.
Report Your Disability
Inform them that you need to file a disability claim. Provide your name, policy number (if known), Social Security number, your last worked, and why you are unable to work. Let the insurance company decide your date of disability.
Request Claim Forms and Instructions
Ask for the specific claim forms and instructions for filing a disability claim. Inquire about any required documentation they will need from you and your doctors. If they have claim forms tailored to your condition(s) or symptoms, ask for those.
Inquire About Deadlines
Ask about any deadlines for submitting the initial claim forms or supporting documentation.
Step 3
Gather Necessary Information and Documents
Physician Support
It is critical to have your treating physicians actively support your disability claim. They will need to provide detailed medical information and opinions regarding your diagnoses, symptoms, functional limitations, and inability to work. Dorian Law can guide you on how to work effectively with your doctors to obtain the necessary medical support for your claim.
Medical Records
Complete medical records related to your disabling condition(s), including:
Diagnosis and medical history
Physician notes and reports
Test results (imaging, lab work, etc.)
Treatment plans and progress notes
Medication lists
Functional Capacity Evaluations (FCEs) or other relevant assessments (if available)
Employment and Income Information
Employer Information (for group claims): Employer name, address, contact person (HR), dates of employment, job title, job description.
Income Verification: Pay stubs, W-2s, tax returns to verify your pre-disability earnings.
Job Description: Obtain a detailed job description outlining the essential duties and physical/mental demands of your occupation. Understanding the demands of your occupation is crucial, especially for "own occupation" policies. Dorian Law can help you analyze your job description and how your limitations impact your ability to perform your job duties.
Witness Information (Optional but helpful)
Names and contact information of family members, friends, or colleagues who can provide statements about your condition and its impact on your life and ability to work.
Contact Information and Treatment Dates
Contact information for all providers, such as doctors, specialists, therapists, hospitals, clinics, etc. Dates of office visits, hospitalizations, tests, procedures.
Policy Information
Policy number, group plan name (if applicable), insurance company contact information, policy documents.
Step 4
Complete and Submit the Claim Forms and Documentation
Retain copies of all claim forms, documents, and correspondence you submit for your records
Obtain Attending Physician Statement (APS) or Equivalent
Insurance companies will typically require your treating physician(s) to complete an Attending Physician Statement (or similar form). Provide these forms to your doctors promptly and follow up to ensure they are completed thoroughly and returned to the insurer. This is a critical step, and Dorian Law can help you communicate effectively with your doctors to ensure the APS form provides strong support for your claim.
Obtain and Review Claim Forms
Carefully review the claim forms provided by the insurance company or plan administrator. Understand all required information and instructions.
Complete Forms Accurately and Legibly
Fill out all sections of the claim forms completely, truthfully, and legibly. Ensure all details are accurate (i.e. if you are estimating, say so!). This is not the place for hyperbole.
HYPERBOLE
Submit All Supporting Documents
Assemble all the necessary documents gathered in Step 3, including medical records, employment information, and completed claim forms and APS. Submit them to the insurance company or plan administrator using the method specified in their instructions (e.g., mail, online portal).
Step 5
Follow Up and Cooperate with the Insurance Company
Note Submission Date and Method
Record the date you submitted your claim and how you sent it. Consider sending via certified mail with return receipt requested for proof of delivery, especially when mailing physical documents.
Follow Up Periodically
If you haven't heard back from the insurance company within a reasonable timeframe (e.g., 2-4 weeks, or as indicated in their claim instructions), follow up to inquire about the claim's status. Be polite but persistent. Be particularly diligent in ensuring they receive your information, it is very common to hear client say the insurance company consistently “never received” records.
Keep Records of Communication
Document all communication with the insurance company, including dates, names of representatives, and summaries of conversations. Retain copies of emails and letters.
Track Your Claim (If Possible)
If the insurer provides a claim tracking number or online portal, use it to monitor your claim status.
Respond to Requests Promptly and Fully
Insurance companies may request additional information or documentation during the claim review process. Respond to these requests promptly and completely. Delays in responding can slow down your claim processing.
Step 6
Understand the Claim Decision and Your Options
Review the Claim Decision Letter
Once the insurance company has reviewed your claim, they will send a decision letter, typically explaining whether your claim is approved or denied.
If Approved
The letter will outline the benefit amount, start date, and payment method. Confirm these details and understand the ongoing requirements for continued benefits (e.g., periodic medical updates).
If Denied
Carefully review the denial letter. Understand the exact reason for the denial. If you believe the denial is wrongful or unclear, do not hesitate to seek legal advice from Dorian Law. We can analyze the denial, policy terms, and circumstances to determine if the denial is justified and advise you on your appeal rights and options.
If your claim is governed by ERISA, you may have as little as 180 days to appeal an adverse benefit decision (even a partial payment). Failure to appeal within the time stated in the denial letter may prevent you from challenging the denial in court.
You Must Appeal Within the Stated Time
Common Issues and How Dorian Law Can Help at the Initial Claim Stage
In most situations, Dorian Law does not recommend hiring an attorney to assist with making a claim. However, challenges can arise and, in some situations, having counsel from the start is effective. Dorian Law is experienced in assisting clients with:
Understanding Complex Policy Language: We can review your policy and explain complex definitions, exclusions, and limitations in plain terms.
Gathering and Presenting Persuasive Medical Evidence: We can guide you on what medical documentation is most important and how to work with your doctors to obtain strong medical support for your claim.
Completing Claim Forms Accurately and Strategically: We can assist you in completing claim forms accurately and in a way that best presents your case to the insurer.
Communicating Effectively with Insurance Companies: We can handle communications with the insurance company, ensuring your rights are protected and your claim is properly presented.
Navigating "Own Occupation" vs. "Any Occupation" Definitions: We can strategically present your case based on the specific definition of disability in your policy.
Frequently Asked Questions (FAQ) About About Making a Disability Claim
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A: Probably not, but consulting with Dorian Law at the initial claim stage can be incredibly beneficial. We can provide guidance, review your policy, and give tips with claim preparation and help you avoid common pitfalls that can lead to denials. Engaging us early can increase your chances of initial claim approval and reduce stress during a difficult time.
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A: File your claim as soon as reasonably possible after you become unable to work due to disability. Check your policy for any specific notification deadlines. Prompt filing ensures timely processing, avoids potential delays, and eliminates problems with notice provisions in the policy.
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A: You need to submit comprehensive medical records documenting your diagnoses, symptoms, treatment history, functional limitations, and physician opinions regarding your inability to work. Obtain records from all treating physicians and medical providers.
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A: An Attending Physician Statement (APS) is a form that your insurance company will ask your treating physician to complete. It asks your doctor to provide detailed information about your medical condition, treatment, functional limitations, and ability to work. The APS is one of the most critical pieces of evidence in your disability claim. Be sure it is completed in the same way as your other forms: completely, legibly, and accurately. Sometimes the forms are designed to be misleading, so make your treatment provider aware they can modify questions to fit your situation.
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A: Provide a detailed and accurate description of your occupation, focusing on the essential duties and physical and cognitive demands of your job. If you have an "own occupation" policy, emphasizing the specific requirements of your particular occupation is crucial.
Filing a disability insurance claim should be straightforward, but unfortunately, it isn't always. Insurance companies are large businesses, and claim denials can happen, adding unnecessary stress when you are unable to work.
You don't have to go through this alone. If you have concerns, contact Dorian Law for a free consultation. We are here to provide the compassionate support and, if appropriate, the effective legal representation you need to secure your disability benefits.