In this several-part blog series titled The Basics of an ERISA Life, Health and Disability Insurance Claim, we discuss the basics of an ERISA life, health, accidental death and dismemberment and disability claim, from navigating a claim, to handling a claim denial and through preparing a case for litigation. In Part Two of this series, our focus in this article will be on the filing of a claim.
Often, clients contact our firm before they have filed any life, health, accidental death and dismemberment and disability claim for benefits with their insurer. In these circumstances, we can assist them on an hourly or contingency fee basis. Our firm is able to put the client in the best position possible to ensure their claim gets paid. Before collecting documents and submitting a claim to an insurer, it is important to determine first if there are any issues with the timeliness of a claim.
Most first-party insurance policies, including life insurance, disability insurance, property insurance and liability insurance policies, require that an insured policyholder provide notice of a claim within a specified period of time, typically, “as soon as practicable,” “during the Elimination Period” or a similar formulation. See e.g. Ins. Code Section 10350.7 (requirement in disability policies). With respect to liability insurance policies, notice of a claim is required in both claims-made and occurrence policies. Notice generally must be given within a “reasonable time” or within a specified period. Insurance policies often specify that timely reporting of claims is a condition precedent to coverage. While there are different rules for insurance policies that require a timely notice of a claim, a policy-holder friendly rule known as the “notice-prejudice rule” has been adopted by the California courts. The rule provides that unless an insurer can demonstrate actual, substantial prejudice from late notice of a claim, the insured’s failure to provide timely notice will not defeat coverage. See our Blog post regarding the Notice-Prejudice Rule here.
There are many steps we can take to assist our clients with filing claims for insurance/ERISA benefits, even if a claim has already been filed and before an insurer has made a decision on a claim. With respect to a short-term disability or long-term disability claim, we can assist our clients with obtaining key documents to start the claim process. We can also assist with obtaining the necessary claim forms to file a disability claim and to obtain a copy of the disability insurance policy. It is critical that we review the policy to give our client advice about the claim, including the type of claim to file (e.g., total vs. residual disability, mental vs. physical, etc.). For example, if a client wishes to assert a mental-nervous claim, we will evaluate whether such a claim will be limited to a period of years (such claims are typically limited to two years of benefits) and we will evaluate if there is a “physical” cause of the disability our client can assert that could potentially give our client far more benefits for a much longer period of time. We will also evaluate what type of evidence will be required to prove the claim. We can assist the client with obtaining medical records, physician certification letters, attending physician’s statements, personal statements/letters in support of a client’s disability from the client, his/her family and friends. We can also work with the client to obtain the necessary experts to support the type of medical claim at issue. Due to our history of handling claim denials with insurers, we can perform an analysis of ways an insurer might attempt to deny a client’s disability claim, review all claim forms and medical records before submission, and ensure that there are no inconsistencies or irregularities in any of the documents. We can also assist the client with answering questions regarding how their disability affects their activities of daily living and their work, how best to identify the client’s occupational duties, how best to identify how long they can sit/stand/walk, and other information in support of a disability.
Many clients attempt to submit claims on their own, and often fall into pitfalls set by insurance companies that are structured to help an insurer deny a claim. We can assist in navigating the maze of rules and traps insurers set. Retaining an attorney early in the claim process to handle this process will maximize the likelihood a claim with get approved, and help to ensure ongoing future benefit payments.
Later in our Blog series, we will discuss the denial of a disability insurance claim, and steps to taking regarding an appeal of an insurer’s claim denial.
