HEALTH INSURANCE UNDERWRITER (N.A.H.U.)
"ABANDONMENT: One of Many Claim Management Strategies in the Disability Claims Arena"

Picture this scenario: in the past, you were a successful dentist, surgeon, or chiropractor. Your hands were your livelihood. You worked in an area that involved a fine degree of tolerance, an area in which a mistake could be detrimental to the well being of your patients. This mistake could cause you to do a less than perfect job. Mistakes were not what you were taught in your years of training. Perfection was routine because anything less was not good enough.

Scene I
One day you notice that your hands are not reacting in the same way to which you are accustomed. The feeling and sensitivity are no longer there, or your fingers can no longer "do the walking" because of the pain you are experiencing. You may take medication to reduce or relieve the pain, or you might turn to alcohol or even illegal drugs. You may even be in denial because, as you say to yourself, "this can't be happening to me."

You are a healer, a sculptor. Even with a great deal of expertise and perfectionist qualities, you may still not do the job to your complete satisfaction because of the unknown or unexpected. Now your hands are failing you. You do your best to compensate in any one of a number of ways, but the repetitive motions are only making matters worse. It takes you longer to accomplish your tasks, and what was once a normal degree of stress becomes one of larger proportions.

You feel like a horse that has left the gate but isn't going to make it to the finish line. You may slice your hours in half, cut out "on-calls" or be more selective in the number of patients you handle hoping this will solve the problem.

You see various medical specialists who tell you that your symptoms are that of carpal tunnel syndrome, cervical radiculitis, arthritis or any one of a number of similar medical diagnosis. You are no longer a perfectionist. In your heart you still strive for perfection, but the finished product says otherwise.
Working "on the edge" is not your style. The fear of malpractice looms high on the horizon. Permanent injury or even death might be the outcome for your patient. You do the right thing. You throw in the towel and walk away from a profession you love. You are no longer "godlike." You are just another human being who must go on with his life.

But wait-all is not lost. You have a security blanket similar to that teddy bear that you took to sleep as a child. It's called a disability policy. You paid thousands of dollars of hard-earned cash knowing that if you got sick or hurt and couldn't work, you would have a cash flow to maintain a sense of dignity and keep you close to your world-maybe not quite the financial world that you had become accustomed to, but one in which you could go on with your life. Your apprehension lessens and you bless the day that you made the decision to purchase a disability policy. Superman to the rescue-with a money bucket!

You submit a claim. The insurance company honors their obligation and begins to send you checks on a monthly basis. You may not have been made "whole," but you are not going down the toilet from an economic standpoint. You take pride in your decision to have insured your most valuable asset …your ability to earn money. You take for granted that you will continue to receive your checks, and every month that a check is received you take pride in knowing that you made the right decision to purchase insurance against the one contingency you did not want to happen: becoming sick or hurt and not being able to do what you do best.

Scene Two
You receive a letter from your insurance company indicating that it is no longer handling your disability claim. A "management company" will now be involved that will provide the "same quality of service" that you have received in the past. Despite the fact that you may have never heard of this company, you still feel a sense of security assuming the new company will take care of you.

Scene Three
Shortly thereafter, you receive a letter from the management company advising that they would like to have you examined-by someone they hire. This comes in the form of an "independent medical evaluation" (IME) or a "functional capacity test." In spite of the fact that you have been considered disabled for five or 10 years by your former insurance company, the new company is questioning this fact.

You are examined. The examiner sends a report to the insurance company. It states you have "no objective symptoms". Whey they examined you, the examiner did not feel any "tender areas". You are able to move your neck and use your hands in a way that could enable you to go back to your profession.
It is their respected opinion that you no longer meet the criteria for a disabled person within your area of former expertise. You ask the management company for a copy of the examiner's report. They refuse to send it to you. You ask around and find out that they will send it to your attending physician so you request that they do so.

When your attending physician receives the report, he expresses the same degree of shock that you do. He may even write a letter on your behalf that states he has treated you for many years. Who knows your medical situation better than he?

It's true that you are feeling better and may no longer have the numbness or pain that you previously experienced. But why? Because you no longer perform the same repetitive movements that exasperated the symptoms years before.

The management company says that you can go back to work. You haven't held a medical instrument in your hands or used your hands in a clinical fashion in five or ten years. You are "rusty"-incompetent from an educational standpoint-and pose a danger to yourself as well as a patient if you were to go back into practice.

And who would hire you now? What hospital would offer you privileges? Can you set up your own practice with the large up-front investment? Can you do the impossible? Reality now sets in.

Going back to what you loved and did best is no longer an option. The management company sends you a letter indicating that they will no longer be sending you a monthly check. You feel lost. Your insurance company has abandoned you.

Scene Four
As an alternative to the above, the management company sends a representative to see you. They indicate that you should no longer be paid any money but, out of the goodness of their hearts, they want to soften the blow. They offer to pay you eight or 10% of your future benefits in the form of a check now-if you will surrender your policy.
This is called a "buy back." What was once a $3 million dollar potential payout now becomes a $240,000 or $300,000 offer.

You weigh your options: If you don't accept, you face the future of bringing a lawsuit against the management and insurance companies, which can last anywhere from one to five years.

Economically, you will be devastated without the necessary cash flow coming in to pay your mortgage and other expenses. You put your tail between your legs and accept the offer, knowing that you will at least have cash in the bank for the short-term. Your long-term scenario is a bit questionable. But you can't worry about the long-term- you need money now.

You are defeated, abandoned. You call the insurance company that sold you the policy. They tell you it's not their decision. They no longer handle your claim. They extricate themselves from any blame. You call the broker/agent who sold you the policy. He or she may even make a few phone calls on your behalf to improve the situation. They feel defeated and abandoned through no fault of their own. Promises made by them have not been kept. They worry about how other clients wilt be treated in the future. They experience frustration and disappointment. Their cries fall on deaf ears.

A bleak picture, indeed, but it can happen!
It is possible, however, with the help of a disability claim consultant, that you may be able to resurrect your claim and reinstate your monthly benefits. Although few and far between, they are out there to provide help when it is needed.

In the worst-case scenario, they can provide assistance to an attorney in preparation of the facts of your case should a lawsuit be necessary. This may not be what you expected or want but, as you know, often the best defense is a good offense.

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Arthur L. Fries, RHU, is an independent life/health broker and a disability claim consultant based in Newport Beach, CA. He can be contacted at (800) 567-1911 or via www.afries.com.

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