Helping Your Client To Put Her Best Foot Forward In Making Her Disability Claim Eric Ratinoff (916)448-9800 [email_address]
Why do people buy insurance? What do the insurance companies tell us about why we should buy insurance? What do agents and...
“Peace of mind” “Protection against calamity” “Security” “Responsibility” “Family” “Because you never know what will happe...
Your client becomes disabled: What does she do? <ul><li>She contacts her agent / broker who sold her the policy </li></ul...
Everyone tells her to “file a claim” <ul><li>The agent / broker may contact the company for her and get the ball rolling. ...
How does she successfully make her claim, now that her claim has been “filed”?
Get her insurance documents together: <ul><li>Insurance policy </li></ul><ul><li>Declarations pages </li></ul><ul><li>Appl...
Proof in support of the claim: <ul><li>Physician statement: provides “regular attendance” for the disabling condition </l...
Insurance company’s duties: <ul><li>Thoroughly investigate the claim </li></ul><ul><li>Promptly investigate the claim </li...
What is “Total Disability”: <ul><li>“ Unable to perform the substantial and material duties of one’s own occupation. . ....
“ Substantial and Material duties” <ul><li>“ [T]otal disability does not signify an absolute state of helplessness but me...
Total Disability not determined in a vacuum <ul><li>An employee is totally disabled “whenever the employee is prevented fr...
Prepare for Insurance Company Defenses to Coverage: <ul><li>Not Disabled: evidence of disability </li></ul><ul><li>Inconte...
ERISA -- Exceptions <ul><li>Independent contractor (unless she obtains the insurance benefits through group plan that cove...
Stuck with ERISA? <ul><li>Read and re-read the Plan documentation </li></ul><ul><li>Must exhaust administrative remedies –...
“Independent” medical exam: <ul><li>Policies universally require the insured to assist in the evaluation of the claim </li...
Game Plan: Give The Insurance Company Every Reason to Pay the Claim <ul><li>Be prepared </li></ul><ul><li>Cooperation is ...
What if the insurance company refuses to pay the claim in whole, or in part? <ul><li>Consult with a qualified, knowledgeab...
About your speaker:
ABOUT YOUR SPEAKER <ul><li>Eric Ratinoff represents plaintiffs in all areas of insurance bad faith and personal injury lit...
END Eric Ratinoff (916)448-9800 [email_address]
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Helping Your Client To Put Her Best Foot Forward In Making Her Disability Claim

Nuts and bolts presentation geared toward assisting consumers in making a disability insurance claim.
Published on: Mar 3, 2016
Source: www.slideshare.net


Transcripts - Helping Your Client To Put Her Best Foot Forward In Making Her Disability Claim

  • 1. Helping Your Client To Put Her Best Foot Forward In Making Her Disability Claim Eric Ratinoff (916)448-9800 [email_address]
  • 2. Why do people buy insurance? What do the insurance companies tell us about why we should buy insurance? What do agents and brokers tell us about insurance?
  • 3. “Peace of mind” “Protection against calamity” “Security” “Responsibility” “Family” “Because you never know what will happen in the future” “Financial planning”
  • 4. Your client becomes disabled: What does she do? <ul><li>She contacts her agent / broker who sold her the policy </li></ul><ul><li>She contacts the insurance company </li></ul><ul><li>She reads her policy </li></ul>Her overriding emotions are fear and confusion: “I have this policy and I don’t understand it – what am I really supposed to do?”
  • 5. Everyone tells her to “file a claim” <ul><li>The agent / broker may contact the company for her and get the ball rolling. </li></ul><ul><li>The company will provide a claim form, a medical authorization form, and a physician’s statement form. </li></ul>Does she really understand what it means to “file a claim”?
  • 6. How does she successfully make her claim, now that her claim has been “filed”?
  • 7. Get her insurance documents together: <ul><li>Insurance policy </li></ul><ul><li>Declarations pages </li></ul><ul><li>Application </li></ul><ul><li>Riders, endorsements, and amendments </li></ul><ul><li>Premium payments – cancelled checks, bank statements, receipts, premium lapse notices </li></ul><ul><li>Claim notices </li></ul><ul><li>Proof of loss </li></ul><ul><li>Correspondence between the client and the insurance company, agents, etc. </li></ul><ul><li>Insurance company fliers and advertising </li></ul>
  • 8. Proof in support of the claim: <ul><li>Physician statement: provides “regular attendance” for the disabling condition </li></ul><ul><li>Medical records </li></ul><ul><li>Pertinent radiology or other diagnostic studies </li></ul><ul><li>Accident report </li></ul><ul><li>Vocational rehabilitation consultation </li></ul><ul><li>W-2s, 1099s, tax returns </li></ul>
  • 9. Insurance company’s duties: <ul><li>Thoroughly investigate the claim </li></ul><ul><li>Promptly investigate the claim </li></ul><ul><li>Be objective and give the insured’s interests at least as much consideration as it does its own interests </li></ul><ul><li>Timely respond </li></ul><ul><li>Obtain information directly from the treating doctors </li></ul><ul><li>Timely pay all the benefits owed under the policy </li></ul>
  • 10. What is “Total Disability”: <ul><li>“ Unable to perform the substantial and material duties of one’s own occupation. . .” </li></ul><ul><li>“ Unable to perform the substantial and material duties of any occupation. . .” </li></ul>
  • 11. “ Substantial and Material duties” <ul><li>“ [T]otal disability does not signify an absolute state of helplessness but means such a disability as renders the insured unable to perform the substantial and material acts necessary to the prosecution of a business or occupation in the usual or customary way. Recovery is not precluded . . .because the insured is able to perform sporadic tasks, or give attention to simple or inconsequential details incident to the conduct of the business. . .” Erreca v. Western States Life Ins. Co. (1942) 19 Cal.2d 388, 396. </li></ul>
  • 12. Total Disability not determined in a vacuum <ul><li>An employee is totally disabled “whenever the employee is prevented from working with reasonable continuity in his customary occupation . . . or . . .another occupation in which he could reasonably be expected to perform satisfactorily in light of his age, education, training, experience, station in life, physical and mental capacity.” Moore v. American United Life Ins. Co. (1984) 150 Cal.App.3d 610, 618. </li></ul>
  • 13. Prepare for Insurance Company Defenses to Coverage: <ul><li>Not Disabled: evidence of disability </li></ul><ul><li>Incontestability clauses: typically limited to two years </li></ul><ul><li>Preexisting condition: limited to two years; acts and omissions of the insurer’s agent imputed to insurer </li></ul><ul><li>First manifestation of illness: the incontestability clause bars the insurer from denying the claim after two years </li></ul><ul><li>Legal disability: key question is whether the sickness occurred first. </li></ul><ul><li>Dual occupation at onset of disability: “real occupation” or “chosen profession”? </li></ul><ul><li>Insured chooses not to work: proof of disability and work ethic </li></ul><ul><li>Insured is seeking financial gain: proof of disability, financial loss, and work ethic </li></ul>
  • 14. ERISA -- Exceptions <ul><li>Independent contractor (unless she obtains the insurance benefits through group plan that covers the employees of the company) </li></ul><ul><li>Government employee </li></ul><ul><li>Public agency employee (unless plan also provides group coverage for non-public employees) </li></ul><ul><li>Church employee </li></ul><ul><li>Sole proprietor and spouse (so long as the plan does not provide benefits to other employees) </li></ul><ul><li>No intention by employer to establish ERISA plan </li></ul>
  • 15. Stuck with ERISA? <ul><li>Read and re-read the Plan documentation </li></ul><ul><li>Must exhaust administrative remedies – must timely make the claim and all appeals </li></ul><ul><li>“ Administrative record” is most important thing the court will consider </li></ul><ul><li>LOAD THE ADMINISTRATIVE RECORD </li></ul><ul><li>Federal Court – unanimous jury </li></ul><ul><li>Standard of Review – “arbitrary and capricious” vs. “de novo” </li></ul><ul><li>No general or punitive damages </li></ul><ul><li>Attorneys fees are recoverable </li></ul>
  • 16. “Independent” medical exam: <ul><li>Policies universally require the insured to assist in the evaluation of the claim </li></ul><ul><li>Policies universally require the insured to submit to medical examination by a physician of the insurer’s choosing </li></ul><ul><li>Essentially unlimited right under most policies – frequency, duration, and conduct of the examination must be reasonable </li></ul>
  • 17. Game Plan: Give The Insurance Company Every Reason to Pay the Claim <ul><li>Be prepared </li></ul><ul><li>Cooperation is important </li></ul><ul><li>Provide all the pertinent medical information </li></ul><ul><li>Provide five years earnings history (if available), including w-2s, 1099s, and tax returns </li></ul><ul><li>Provide job description from employer </li></ul><ul><li>Get the physician on-board to cooperate </li></ul><ul><li>Get the employer on-board to cooperate </li></ul><ul><li>Timely submit the claim </li></ul><ul><li>Timely submit all requested information </li></ul><ul><li>Participate in “independent” medical examinations </li></ul>
  • 18. What if the insurance company refuses to pay the claim in whole, or in part? <ul><li>Consult with a qualified, knowledgeable lawyer with a successful record of making insurance companies pay legitimate claims. </li></ul>
  • 19. About your speaker:
  • 20. ABOUT YOUR SPEAKER <ul><li>Eric Ratinoff represents plaintiffs in all areas of insurance bad faith and personal injury litigation. He has successfully tried and settled numerous cases on behalf of his clients. Mr. Ratinoff's successes on behalf of his insurance clients include large recoveries in the following: bad faith denial of insurance claims involving disability, health, auto, property, long term care, business, fire, property and casualty, commercial and life policies. Mr. Ratinoff is a graduate of the Spence Trial Lawyers College. He is a past President of the Capitol City Trial Lawyers Association (&quot;CCTLA&quot;). Mr. Ratinoff is a member of the Board of Sierra Adoption Services, and he is the incoming President-Elect. Mr. Ratinoff is also a member of the Northern California Board of AIPAC, and is a member of the Sacramento Rotary Club.   </li></ul><ul><li>Contact </li></ul><ul><li>Email: [email_address] </li></ul><ul><li>Tel.: 916-448-9800 </li></ul><ul><li>Fax: 916-669-4499 </li></ul>
  • 21. END Eric Ratinoff (916)448-9800 [email_address]

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