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Claimant's Bill of Rights:
You have the right of full disclosure.
As the insured party to a disability contract you have the right
to receive and examine all collected data, both paper and
electronic collected by the disability insurer in the process of
reviewing your claim for benefits. This includes all
administrative and chronological records, conversations,
meetings, data base checks, field surveillance, and any other
data affecting your privacy as an individual. This information
must have been used by the insurance company to deny your claim
for benefits. Under ERISA regulations you have the right to
receive a copy of your policy and claim file within 30 days of
requesting it. If it has not been provided to you within the
designated time frame, the insurance company may be fined $110
per day.You have the right to privacy and respect.
You have the right to expect medical records and any other
private information which reflects upon your credibility,
integrity or reputation, to be kept private and treated with
respect. You have the right to know what type of information is
requested over and above that which is needed in making a fair
decision on your claim. You have the right to know when your
claim is being reviewed in a public forum and by whom. (Such as
roundtables.) You also have the right to know the name and title
of the person who will actually be making the decisions on your
claim. Quite often, it is not the claims specialists who do
this.You have the right to a timely claim decision.
You have the right to expect your disability insurer will make
every effort to render a claims decision within 30 days (ERISA
claims) or that period of time indicated in the policy
provisions. You have the right to be notified in writing every
30 days as to the reason why your claim decision is delayed.
ERISA regulations require the insurance company to keep you
informed by sending “tolling letters” if the claim decision is
not make within the 30 day period.You have the right to a
fair and objective claim review.
You have the fiduciary right to expect your disability insurer
will make every effort to consider ALL recommendations and
opinions given to the insurer by your primary care physicians,
consultants, counselors, and any other specialist who is
qualified to render an opinion concerning your ability to work.
(ERISA claims or industry standards if an Individual Disability
policy) You have the right to expect the disability insurer will
consider the experience and qualifications of your doctor as
equal to those of its own in-house physicians, and to make fair
and honest attempts to reconcile professional differences of
opinion.You have the right to fair representation of fact.
As the insured you have the right to a clear understanding as to
the party or parties responsible for making the liability
decision for your claim. You have the right to know who is
authoring communications to you from your insurer, and the names
of all employees, consultants, directors, and others who are
offering medical or administrative opinions concerning the facts
of your claim.You have the right to withhold authorization
of release of information which is overly broad.
Any individual has the right to retain privacy rights to
information without fear of loss of benefits. It is your right
not to sign Authorizations of Release which are overly broad,
or, which allows the disability insurer to obtain information
outside of what is required for a fair and objective review of
your claim within the provisions of your policy. Many of the
newer ERISA disability policies contain provisions which require
you to sign an Authorization and cooperate with the insurance
company or risk loss of benefits.You have the right to ask
questions.
As an individual outside of the specialty of the insurance
industry, or understanding of that industry, you have the right
to knowledge, explanation, definition, instruction and full
understanding of the provisions of your policy without fear of
loss of benefits. You have the right to ask questions concerning
your claim as often as is necessary for your understanding of
the facts without fear of retaliation, suspicion, or unfair
investigation tactics.You have the right to ethical conduct.
As an insured you have the right to expect your disability
insurer, and its representative employees act in “good faith.”
You have the right as an employee or policyholder to expect your
insurance company creates and maintains a clearly defined
disability claims review process which lends toward the fair,
objective and timely, review of all claims submitted as part of
its product business. You have the right to expect your
insurance company have in place a process which routinely and
consistently corrects flaws within the review process; recruits,
trains and retains individuals qualified to review disability
claims; and provides a forum for independent appeal processes.
You have the right of non-discrimination.
All insured have the right to expect their insurance company not
discriminate on the basis of indemnity amount, self-reported or
physical impairment, education, training or experience,
occupation, age, sex, mental and nervous disorder. Policyholder,
geographical region, claim location, event, physician, claim
duration, months of paid benefits, or any other target objective
identified by management. You have the right of expectation that
your claim will not be targeted by management for denial as a
“block of business” due to any of the above.You have the
right of appeal.
As an insured covered under the Employment Retirement Security
Act of 1974 (ERISA) you have the legal right to a timely
independent appeal review of your claim. For non-ERISA
individual disability claims, you have the right to report
discrepancies to your state authorities and to retain legal
counsel, and request “reconsideration” of the denial decision.
This "Bill of Rights" was written by Linda Nee, a Disability
Claims Consultant. Although there is no law or regulation
upholding these rights as an official document, the rights
described herein are reasonable and should be expected from any
disability insurer with a duty to uphold generally accepted
industry standards to review claims objectively, and without
bias or financial prejudice.
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