If you are injured, don’t expect to file a disability claim and immediately start getting checks. It doesn’t work that way.
Even though Disability Income insurance is not the first thing that comes to mind when most people hear the phrase, “Health Insurance,” it is not in a category of its own. Disability insurance is a form of health insurance in most states.
Both private and public insurance companies have their own set of requirements that must be satisfied before a disability claim is approved.
Private disability insurance generally moves faster that Social Security when it comes to a disability claim but every private insurance company has their own way of handling them. The one thing in common in all insurance companies, private or public, is that humans are involved at some point. Whether the entire claim is processed directly by a human or was kicked out by a computer because of a coding mistake, a human being was involved somewhere along the line.
Because a human being is involved and humans can make mistakes, it is possible for a legitimate claim to be adversely acted on.
Before you go to the trouble of hiring an attorney and get things clogged up in court, contact your state’s Department of Insurance. Section 2793 of the PPACA requires each state to develop an Office of Consumer Assistance or Ombudsman to help insured’s with the following.
The office of health insurance consumer assistance or health insurance ombudsman shall—
1) assist with the filing of complaints and appeals, including filing appeals with the internal appeal or grievance process of the group health plan or health insurance issuer involved and providing information about the external appeal process;
2) collect, track, and quantify problems and inquiries encountered by consumers;
3) educate consumers on their rights and responsibilities with respect to group health plans and health insurance coverage;
4) assist consumers with enrollment in a group health plan or health insurance coverage by providing information, referral, and assistance; and
5) resolve problems with obtaining premium tax
The new federal legislation known as the PPACA requires private insurance companies to have internal appeals processes for people who have had their claims denied or paid in an unsatisfactory manner. If a person does not feel that they have been treated correctly by the insurance company, they should first contact their state’s Department of Insurance to see what the appropriate steps are in your state.
Remember, insurance companies are more afraid of state Departments of Insurance than they are the courts. All a court can do is require them to pay the claim and monetary penalties after months and years of potential litigation. The Department of Insurance, on the other hand, has the ability to threaten private insurance companies with even stiffer penalties if a company is not honoring a legitimate claim.
The key is “legitimate claim.” The policy you agreed to is a contract. Both parties, the insurance company and you have rights and responsibilities. If you have done what your policy requires and your claim is still not paid, you have a “legitimate claim.”
If, on the other hand, you have not done what you are required to do, your claim is not “legitimate.” No matter how big a stink you raise, the insurance company is not required to pay your claim.
In other words, when you get your policy make certain you read it so that you know what you need to do to guarantee you don’t have a claim problem in the future.
While I am definitely not a toady for the health insurance companies, I do know from experience that the vast majority of claims disputes would not occur if people took the time to understand how their health insurance worked before they experienced a claim.
If you have read your policy and done what is required of you and your claim is still denied your first step will probably be to file an internal appeal with your insurance company. Your claim will be reviewed by a different human or group of humans to see what, if any mistakes were made the first time. If you have a legitimate claim to benefits based on your policy, the appeals process should make things right with their apologies.
Remember, if you have any new information, this is probably a good time to give it to your insurance company.
If, however, your claim is still denied by the internal appeals process and you feel their decision is the wrong one, your next step will be to file an external appeal in which your state’s Office of Consumer Assistance or Ombudsman will take a more active role.
Each state is different but it is likely that a board of specialists representing both the interests of the insurance company and consumer advocates will meet to review your case and make an enforceable decision.
Public (Government) Insurance
Federal, government run insurance companies, such as Social Security do not have the same consumer protections like the Office of Consumer Assistance. Since Social Security Disability insurance is run by the federal government it is not subject to the state laws. They have a different, more complicated appeals process.
You may have to get an attorney to help you with your claim. Although you are allowed to file your claim on your own, if you are truly disabled you probably already have enough with which to deal. An attorney with knowledge of the Social Security Disability Insurance program should be able to expedite your claim through the federal “red tape.”
Read more about your rights to representation with your Social Security disability claim at the link provided.
It is also important to remember that if you are seeking Social Security Disability insurance you should start the process as soon as you can. Like many beaurocracies a great deal of time can pass between the time you actually file a claim and the time you receive any money.
The information in this web site is a little dated but it is not likely to have drastically changed in two years. Read the article, “How Long Does a Social Security Disability Claim Take” to get an idea of how long you may have to wait for a decision from them, depending on which area of the nation you live.
The information above is not meant to scare anyone with a legitimate disability from filing a claim. I just want people to have realistic expectations. Whether the disability insurance you are counting on is with a private or public insurance program, my advice is the same. File your claim as soon as you get an inkling that you may be disabled.
Don’t “wait and see.” If you are disabled it only delays you getting benefits. If you are not disabled you can always cancel your claim.
If you have no disability insurance or are just confused contact The Insurance Barn at firstname.lastname@example.org or call us at (832) 767-8059.
- How To Avoid Health Insurance Claim Problems (theinsurancebarn.wordpress.com)