The start of every disability insurance claim process is the completion of forms the claimants is required to submit to receive benefits. While the forms are ostensibly designed to be clear and straightforward, the questions asked on the disability insurance claim forms often confuse claimants, and ambiguities in disability insurance claim forms can lead to misunderstandings and delays in the processing of claims.

Common Examples of Ambiguities in Disability Insurance Claim Forms

Vague Questions Asking Claimants to Describe Their “Disability”:

One of the most common ambiguities in disability insurance claim forms involve questions that inquire about the basis of the claim. Many claimants are confused because they are led to believe they can only list one medical condition when there may be several conditions acting in combination with one another that result in disability.

Unclear Medical Information:

Disability insurance claim forms often require detailed medical information about the claimant’s condition. However, the forms may not provide clear guidance on what specific information is needed. This often leads to incomplete or inaccurate responses, which can delay the processing of the claim.

Confusing Questions That Cause Misunderstanding:

Disability insurance claim forms may contain complex or confusing questions that are difficult to understand, resulting in misunderstandings about what is being requested and leading to errors in the information provided. One example is where the claim form asks if the disabling impairment is “work related.” Many claimants understand that question to ask whether their condition affects their ability to work, but what the insurance company is really seeking is information about whether the claimant is pursuing a workers’ compensation claim. Claim forms also often use technical terms that are not easily understood.

Insufficient Space Provided:

The claim forms are designed in such a way that claimants are unable to provide sufficient information in the space provided. One example is claim forms that only have space to list two or three treating physicians and preclude claimants from listing all of the doctors who have been consulted and who may have relevant information. Claimants need to understand that there is nothing wrong with adding additional information on a separate sheet, but the claim form is not intended to be comprehensive, and claimants do not need to write lengthy statements.

Inconsistent Terminology:

Disability insurance claim forms may contain inconsistent terminology, which can lead to confusion and errors. For example, the form may use different terms to describe the same condition or may use medical jargon that is unfamiliar to the claimant. Another example is when a claim form inquires whether the disability is due to a “sickness” or an “accident.” Those are not necessarily easily understood terms, especially where there may be an accident that has worsened an underlying illness or a condition resulting from repetitive stress injuries.

Lack of Clarity in the Claim Process:

Disability insurance claim forms may not provide clear guidance regarding the claim process. Shortly after the initial claim forms are submitted, the insurer will likely contact the claimant by telephone to conduct a more detailed interview in order to learn more about the basis of the claim. Insurers will often collect medical records from the treating doctors and then have the claim evaluated by a medical consultant or there may be a request by the insurance company to have the claimant examined by a doctor chosen by the insurer. When a claimant is unaware of the process and time frame as to how a claim is evaluated, it can lead to misunderstandings about what is required and when, which can delay the processing of the claim.

Confusing Attending Physician Statements:

In addition to the claim forms completed by claimants, the attending physician certification of disability forms can also be filled with ambiguities. Some forms do not give the treating doctor sufficient space to provide necessary elaboration or give doctors choices to check off regarding their patient’s condition that do not give the doctor the option to indicate that a patient is completely incapable of working. Other forms may not give the doctor an option to list non-exertional impairments such as seeing, hearing, pain, fatigue, or dizziness. Courts have repeatedly criticized insurance companies for asking physicians to complete ambiguous forms and then taking advantage when the doctor misunderstands or fails to provide complete information. Yet ambiguities persist.

Minimizing Risks of Mistakes Due to Ambiguities in Disability Claim Forms and Process

Dealing with ambiguities in disability insurance claim forms can be challenging, but there are steps that can be taken to minimize the risks of mistaken or incomplete answers. Here are some tips for navigating the claims process:

  1. Seek help from an experienced professional: If you are unsure about how to complete a disability insurance claim form, seek help from a professional. A lawyer experienced in handling disability insurance claims can offer guidance on what information is required and how to accurately and completely fill out the claim forms.
  2. Review the form carefully and ask for clarification of anything that is unclear: While claim forms need to be returned promptly, they do not need to be returned immediately. Claimants should take the time necessary to review the disability insurance claim form carefully before submitting it and should review and edit draft answers before returning the forms to the insurance companies. Claimants need to make sure they understand each question and provide accurate information; and if they are not working with an attorney, there is no prohibition against calling the insurance company and asking for an explanation of what is being requested. Claimants should also keep copies of all documentation submitted to the insurance company – it will come in handy later when the insurance company conducts a more comprehensive field interview but it may also be needed if other questions arise during the claim process. This includes the claim forms, medical records, and correspondence with the insurance company.
  3. Follow up regularly: Once the disability insurance claim forms have been submitted, claimants should follow up regularly with the insurance company to ensure that the claim is being processed in a timely manner and to verify that the insurance company has all the information it needs to process the claim.

Are there Remedies for ERISA Plaintiffs Who Are Denied Coverage Due to Ambiguous Questionnaire?

When an ERISA plaintiff is denied coverage due to an ambiguous questionnaire, there are legal remedies available to challenge the denial of disability benefits. ERISA plaintiffs can bring a lawsuit against the insurance company or the plan administrator and argue that the insurer’s reliance on an ambiguous questionnaire violated its duty to provide full and fair review. Additionally, the plaintiff may seek to have the court require the insurer to pay benefits and attorneys’ fees. However, it is important to note that the legal process can be complex and time-consuming, and it is advisable to seek the assistance of an experienced ERISA attorney to help navigate the process.

Conclusion

Ambiguities in disability insurance claim forms can create challenges for claimants, but with careful attention and assistance, these challenges may be overcome. Seek help from disability insurance attorney, review forms carefully, ask for clarification, keep documentation, and follow up regularly to enhance the likelihood that the claim will be successful.

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