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Life's a Risky Business: Can You Collect on Your Insurance Claim?

By Elaine Sambugaro |

Making a claim: collecting what you're owed

You may have a disability insurance policy and a legitimate claim, but that doesn't mean you will be able to collect - even with the most consumer-oriented policies.

Members of the Pickering-based National ME/FM Action Network say that the number of legitimate claims that have been denied by insurance companies is alarming.

Lydia Neilson, President & CEO, says that their office has been overwhelmed by telephone calls from disabled individuals who cannot collect DI. She says that the one thing they have in common is that they were denied benefits because they failed an independent medical examination conducted by physicians known to be affiliated with a specific insurer.

According to HRDC statistics, there are 2.3 million adults aged 15 to 64 with disabilities, representing 13% of the total Canadian working population.

'It's not a gift," Neilson said. "These people paid premiums in the unlikely event that they get disabled. When they're diagnosed with cancer, or liver disease or heart disease, look what happens. It's immoral."

According to Lackman, the claimed absence of adequate medical evidence to support the policy's definition of disability is the most common reason why a company denies a claim. In other words, the claim is denied because the insurer is not satisfied that the person meets the eligibility requirements of that policy. Another common reason for denial, Lackman says, is that an individual no longer qualifies for coverage, based on a doctor's re-evaluation.

"This is not a flat-out denial from the inception, but a denial based on a change or a perceived change in the person's condition," Lackman said. To prevent this from happening, he advises individuals to ensure appropriate medical follow-up so that their conditions are well-documented.

If one day you need make a claim, remember to keep your wits about you. Never assume anything. As an individual making a claim against a large company, this not the time to think that everything will go through without a hitch. Be prepared to work and fight for your rights. Don't depend on someone else to prove that you are disabled. The onus is on you to document everything and do the leg-work to ensure that the insurance company receives all of the medical and legal documentation necessary for the claim to clear.

You should also consider hiring a lawyer. While this could be an unnecessary expense, good legal help could also ensure that you are better positioned if your claim is contested. Insurance companies screen for fraudulent claims, which they say they receive on a regular basis. While screening for fraudulent claims, it is possible that your legitimate claim could be contested. Legal counsel can also assist you by clarifying the meaning of insurance policy jargon – including exclusion clauses – and to identify what your valid claim entails.

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