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Any-occupation disability claims are easy for insurance companies to dispute. Since benefits are only available if the claimant proves his or her inability work in any occupational, a trap exists. The insurance company can point to the fact that it believes the claimant can work in some other occupation and deny the claim. The occupations the insurance company claims the insured can perform often pay substantially less than the one the insured performed before being felled by a disability.
For example, a surgeon may be forced to give up his practice after an accident left him with poor coordination and unsteady hands. The surgeon then files a claim under his or her any-occupation disability policy. In this type of case, insurance companies often argue that though the surgeon cannot operate anymore, the disability is not covered because the surgeon can still get another job.
In reality, the surgeon may find no work in the medical or other field because of a lack of experience. What work the surgeon may eventually find will pay nowhere close to the surgery practice. Because of this, the surgeon experiences severe financial hardship.
Some insurance companies deny such claims in bad faith. The bad faith arises from a desire to avoid paying claims. Insurance companies are more profitable when they pay less in claims. Because of this, insurance adjusters are encouraged to look for reasons to deny claims. Any occupation policies make this easy because their nature provides a built-in defense. To deny the claim, the adjustor just needs to conclude that the insured can work in some other occupation.
In reality, a denial on this basis often falls apart in court. Any-occupation policies require that the claimant be precluded from any occupation he is qualified for based on age, education, training, experience, station in life, and physical and mental capacity. These criteria leave room for interpretation. When an insurance company uses this room for interpretation to deny solid claims and create delay tactics, they harm the insured by acting in bad faith. When an insurance company acts in bad faith, they break the law.
How does the claims process work?
For a claim to be successful, it requires medical evidence. The medical evidence usually consists of doctor’s evaluations, diagnosis, and prognosis. This evidence provides the foundation for proving that the disability exists. Without this proof, the insurance company can claim that no disability exists and deny the claim.
An insurance company that acts in bad faith could attempt to deny the claim by disputing the validity of the disability finding. It may argue that the medical records fail to demonstrate that a disability exists. Most insurance companies employ their own staff of medical people that help evaluate claims in the light most beneficial to the company.
For example, the insurance company may argue that the medical evidence indicates that the insured has the mental and physical capacity to work, even if the insured’s doctor disagrees. This often occurs in the case of mental incapacity. The insurance company may argue that the insured’s medical condition has nothing to do with his or her recent memory or concentration problems, and therefore, the claim should be denied.
The insurance company also evaluates medical evidence in light of what occupations other than the claimant’s current one he or she can perform. The adjustor also looks at the claimant’s work history. The work history provides ammunition for claims denials when the insurance company can argue that the claimant can perform some other job they did in the past, even if it is the remote past.
When insurance companies act in bad faith, they deny claims despite the fact that the work the claimant can perform does not fit his or her age, education, training, experience, etc. For example, the insurance company may argue that a doctor who can no longer practice medicine could go back to work in pharmaceutical sales; however, the claimant’s experience may be very outdated, the claimant may be much older than the people typically hired for that occupation, and the career level would be entry level, paying a tiny fraction of the claimant’s previous income.
Denied claims can be reversed
Insurance companies generally make bad faith arguments because they want to save money on claims. When an any-occupation disability claim is at stake, insurers are able to find a multitude of excuses to delay and deny claims. If your claim has been delayed or denied, contact a disability-claims attorney right away.
Your attorney can evaluate your claim and determine where the insurance company’s denial is wrong. Rather than having to fight the insurance company yourself, you can rely on your attorney to take care of all the sticky details. Often, once an attorney demonstrates to the insurance company that the claim is valid, the company realizes it has little choice but to pay. If the company still refuses, your attorney can take them to court.