What is the one thing that the insurance company would actually be embarrassed about? So embarrassed that it will literally make them red in the face, if they knew that you knew this ONE thing?
We’ve talked about it in several other videos. The insurance company owes you a duty to have a reasonable and principled decision-making process when they review your case. They’ve got to make sure that they are acting in the best interest of the beneficiary of the insurance plan, which is you. So they have to act in your best interest. To do that doesn’t necessarily mean that they have to approve your claim, but it does mean that they need to objectively look at all the information in their claim file and make a reasonable decision based on a principled process.
They will tell you that they did review your case. They will say, “This is our process. We go from A to Z. We cross every T. We dot every I. And we do it all.” But ladies and gentlemen, sometimes they’re just lying.
Real-Life Experience With A Client of Mine
Let me tell you about a client of mine that came to me and had a denial letter from a long-term disability insurance company. It said that she wasn’t disabled for her own occupation. My client could not understand why they would say this. I really didn’t understand why either, knowing what I knew about my client and knowing what I knew about her particular condition and her particular job. Her job was not a sedentary type of job. It was very heavy lifting, heavy-duty. You have to work with people. And knowing what I knew about that job and what I knew about her condition, I thought there’s no way that they can say that she’s not disabled.
So I did the same thing that I do in every case when I first get involved in a case. I ask the insurance company for a copy of their claim file. When I got the claim file in, I looked immediately. Why? Because, when the insurance company gets a claim file, they can’t just let it sit. Same for you – You got to look at it. You got to see what’s in the claim file and then figure out why they’re actually denying your claim. So I looked at this claim file and I really got into the weeds in this claim file, like to the point of comparing the denial letter to the medical reports that were written by the doctors.
You know what I found? I found that the claim review specialist simply copied and pasted everything from the doctor that they hired. They paid money to review that particular claim. Now, these people are hired guns. And it’s one thing to get an opinion from a hired gun that says, “She can do this. She can do this. She can do this. She can do this. Therefore, she is not disabled.” It’s a completely different thing to copy and paste that doctor’s opinion and to make it look like it was the process that the claims review specialist went through.
They didn’t go through a process. Copy and paste is not a reasonable and principled decision-making process. It is a couple of clicks of the mouse. That is insufficient as a matter of law for the insurance company to do in this case and in your case.
How We Got to Victory
So what I did was I created a Word document that compared the doctor’s original words, and then I changed everything that the insurance company said about the claim. You know what? The only thing that really changed was the tense and the pronouns. Instead of saying the claimant, they changed it to you, or her, or something. There was some type of pronoun that was changed. Because the doctors will review the claimant as the claimant and the insurance company is writing a letter to the claimant. So it would be weird if you referred to the person you were sending a letter to as the claimant. You would change that and say, “You went to this doctor. You went to that doctor. Or you can do this, or you can do that.” So all they really did was change the pronouns.
So, next, we appealed. Thought this is liquid gold. I mean, this is wonderful information here that I’ve discovered simply by requesting and actually reviewing the claim file. Not only that, you really have to dig into the weeds and say, “Where did this claim review specialist get their information? How is it to be trusted? And is it simply a copy and paste job, or is it a legitimate, principled, and reasoned review process?” And if they copied and pasted it, I’ll give you the short answer. The answer is no. It’s not. Not by any stretch of the imagination.
So we appealed. I filed about a 34-page single-spaced appeal letter in that case detailing all of the malfeasances that the insurance company had gone through to deny her claim. About 30 days after we filed our appeal, we got a letter from the insurance company saying, “We reverse our decision. We are finding that your client is in fact disabled and eligible for disability benefits.” So that was a victory for us.
Of course, we were pretty proud of that and finding that nugget of information that essentially flipped the insurance company. And I wish I could just be a fly on the wall when the appeal specialist was reading our letter and just shaking his or her head, saying, “Oh my goodness, I cannot believe the review specialist did this. We have to reverse this or else we’re going to end up paying attorney’s fees in federal or district court.” So, fortunately, we didn’t get that far. My client got back pay plus ongoing benefits. I was very happy about that. She was very happy about that. Everyone wins at the end, except for the insurance company.
If you have any questions about that or about the principled and reasonable decision-making process that the insurance company is supposed to go through, send me an email. I’d be happy to respond, give you some insight into some of the other things I’ve found. You’d be surprised. This is not the first time that I’ve found a copy and paste job. I suspect it’s not going to be the last. So make sure that you’re looking out for stuff like this. Copy and paste job is never sufficient for a reasonable and principled decision-making process.