How to Prove That You Are Unable to Work and Entitled to Disability Benefits to Your Insurance Company

By Scott E. Davis, Disability Attorney

The fundamental issue in every disability claim is whether you meet the definition of disability in the disability insurance company’s policy.  What do you need to prove in order to get benefits?

In literally all employer provided disability policies, which are governed by a broad complex Federal law known as ERISA, in some variation you must prove you are unable to work in the occupation you worked in when you initially became unable to work.   It is important to note this definition applies for a given period of time – usually the first 24 months of your disability.

After the insurance company has found you disabled and paid benefits for the first 24 months, the definition of disability almost always changes to one that is much harder to meet – you must be unable to work in any occupation which may exist in the national economy.

After the insurance company has found you disabled and paid benefits for the first 24 months, the definition of disability almost always changes to one that is much harder to meet – you must be unable to work in any occupation which may exist in the national economy.  It is critical you understand how the policy defines disability because it is what you must prove in order to obtain benefits.

Consequently, the $64,000 question is – what evidence must you submit in order to prove you meet the definition?  All disability policies have proof of loss provisions, where there is certain paperwork that must be submitted by you which forms the basis of your “Proof of Loss” or, said in a different way, the evidence which shows you are disabled.

The Proof of Loss information includes certain documents such as the application for benefits, a questionnaire which you complete regarding what medical conditions you have and why they preclude you from working and an Attending Physician’s statement for your treating doctor to complete.  Although the Proof of Loss requirements vary by insurance company, most will almost always include the above documentation.  The questionnaire may also ask questions about your activities of daily living, how you spend your time during the day, whether you are able to accomplish certain tasks within and outside your home such as self care, housekeeping, cooking, shopping, and social interactions.

Although every document you submit to the insurance company to prove your claim is important, none is more important than the Attending Physician statement that your doctor(s) must complete.

Although every document you submit to the insurance company to prove your claim is important, none is more important than the Attending Physician statement that your doctor(s) must complete.  It is critical for this form be correctly completed by your physician and hopefully, with a lot of detail confirming why you are unable to work which includes information such as the restrictions/limitations you have in a work environment.

It is also critical that you and your physician understand the exertional/strength requirements of the job you last performed as well as any job which may exist in the national economy because the insurance company will match your doctors’ restrictions/limitations to your job or any job to determine whether you are unable to do them. 

A frequent problem many individuals have is that neither they nor their doctors appreciate how critical the Attending Physician’s statement is.  For example, your doctor checking one box vs. another box is often the difference between your claim being approved, denied or benefits being continued or terminated.  The trick is knowing which boxes are important.

It is important to understand it is your burden to provide evidence in the form of proof of loss, and to prove that you meet the definition of disability – not the insurance company’s.  Thus, while the insurance company may assist in obtaining medical records, they will not prove your case for you.  We receive phone calls weekly from individuals whose doctors did not complete the forms correctly and the insurance company denied their claim.  We often talk with doctors who admit to us they did not know how to fill out the form properly after knowing their patient’s claim was denied or benefits terminated, or worse, they handed the form off to an assistant who did the same thing.

The bottom line is that unless you have an attorney representing you, nobody is managing or reviewing this information in your claim, it all happens without your knowledge or input.

The bottom line is that unless you have an attorney representing you, nobody is managing or reviewing this information in your claim, it all happens without your knowledge or input.  Indeed, you typically find out after it is too late and your claim has been denied or your benefits were terminated.

As you can imagine, even though your doctor may redo the form to “fix the problem” the insurance company will be very skeptical of any modifications, particularly, if they demonstrate you are now unable to work when the first form erroneously allowed you to work.  Among many strategies, we advise our clients on what the answers need to be so they can take the forms into their doctors to assist the doctor with the answers if necessary.  When the form is completed by your doctor, it is important to review it to make sure that it reflects your level of restriction/limitation and disability.

Many people are surprised to learn that their medical records often do not mention the fact that they are unable to work or when you became unable to work.  This disconnect occurs because treating physicians view their job as treating your medical conditions – not documenting a disability claim.

As a result, you believe your medical records prove your disability claim when they frequently never discuss it.  Indeed, insurance companies frequently deny disability claims because they have found the medical conditions are not severe enough to prevent you from working, or you have not provided sufficient objective medical findings to document your claim, or you have not provided sufficient evidence that proves you “functionally” limited or disabled (i.e. what you are unable to do as a result of your diagnosis).

Simply put, you should view the insurance companies “Proof of Loss” documentation is the bare minimum necessary to prove your claim.  It may sufficient to get your claim approved but often, it is not.

In order to prove your claim, we develop a comprehensive approach to overwhelmingly prove you meet the definition of disability.  You can bet your insurance company has a lot of money and medical/vocational experts who frequently do not see things your way – you better be prepared with a strategy to counter them because they will be involved in your claim.

When a client retains us, we invest our significant expertise, time and money in every case to obtain critical medical, vocational and lay witness evidence which is central to your claim being approved.  Without this type of comprehensive strategy, most individuals have no chance to meet the firepower of the insurance company.  We personally develop a strategy with every client and then aggressively develop it with two goals in mind, 1) We are trying to get the claim approved and benefits paid on a monthly basis, and if this does not occur, then 2) We have a strong record and Proof of Loss with which to take the insurance company into federal court where we will very settle the case based on our many years of litigating cases in Federal court.

You can bet your insurance company has a strategy and game plan of their own, and you better have one as well if you want to get your claim paid.

You can bet your insurance company has a strategy and game plan of their own, and you better have one as well if you want to get your claim paid.  In summary, if you are not certain how to prove your claim or want to consult with us about what we can do for you, please call 1 (800) 588-1710 for a free consultation to learn how we can assist you in your case.  We almost always work on a contingency fee basis, meaning you never pay us a fee unless we win your case and you obtain benefits.

© 2015  Scott E. Davis, Disability Attorney