An initial denial does not mean that the disabled individual has no reason to hope for approval, following completion of certain steps.
The first step: Read the denial letter carefully
• How does the policy define disability?
• What conditions does the contract cover?
• What was the stated reason for the denial?
• What reference, if any, was made to the information in the victim’s medical reports?
• What is the date at the letter’s top? That should be the date when it was written.
It takes time to complete this first step in a thorough manner. For that reason, the recipient of a denial letter should think about seeking the services of a personal injury lawyer in Scarborough.
The date is the starting point for any appeal.
An internal appeal would serve as a show of good faith on the part of the insurance company: The policyholder that has chosen to cooperate with the insurance company is not assured of a win. If cooperation were to lead to a prolonged appeal, the policyholder might even lose out on the chance to file a lawsuit.
An external appeal would end with a decision by a court system or a tribunal with an adjudicator. The policyholder would take the case to court, and would need to hire a lawyer.
Situations where it would be best to have an internal review
The denial of coverage was based on the fact that the policyholder had missed an appointment.
The disability insurance carrier has sought clarification of doctor’s prognosis, and the disabled individual understands what information his or her doctor must share with the insurance company.
The denial was based on the fact that the policyholder had skipped a treatment.
The denied party has sought a reconsideration of the ongoing case and has new evidence available.
Situations where it would be best to have an external review:
A company doctor has examined the allegedly disabled party. No insurance company would be expected to ignore the findings of its own doctor. Still, if it did not like the same findings, it might try scheduling another doctor’s appointment for the allegedly disabled party.
The disabled party has missed a deadline.
The person seeking coverage has a pre-existing condition
No payment was made for medical treatment
The disabled party would like to seek compensation for stress.
The denied party cannot afford to pay a lawyer: With an external review, the winner is supposed to have any fees paid by the defendant, at the request of the courts.
How does the insurance company check on the actions of the covered individual?
The company hires investigators, usually men and women that make observations and use a video camera to track the actions of the observed individual.
