Dealing with your LTD Case Manager to keep your claim on track

Aug 15, 2020 | Long Term Disability

When our long-term disability (LTD) lawyers start working with a new client on their LTD claim, several questions are asked. Details on how the client’s experience communicating with their insurance company are essential for an LTD attorney to know as it can help them decide on an effective strategy. By the time we speak with a new client, they have usually dealt with only one or two case managers (sometimes referred to as claim specialists, claim representatives, or adjudicators). Sometimes, despite the denial of benefits from the insurance company, our clients have had positive experiences with the insurance company overall and feel as though they were respected and heard by the insurance provider. However, this is usually not the case.

Insurance companies are not looking to hand out LTD claim approvals without a fight. Sometimes clients come to Valent Legal because they have felt bullied, manipulated, harassed, and targeted every step of the way. Commonly, the primary source of poor behavior comes from an LTD case manager. Our clients often feel that the insurer’s representatives were “out to get them” and as though they were focused on terminating benefits instead of adjudicating the claim on merit.

Examining the case manager is one of the most important jobs when working on a long-term disability lawsuit. We review how they handled our client’s claim and what led them to their decisions. We’ll gather all relevant documents and ask for detailed explanations about those documents. If the insurance company’s employees and lawyers can question your claim to the fullest extent, then it is only right that you have an experienced LTD attorney question them back. We commonly spend a lot of time asking questions about the policies and procedures that the LTD case manager is required to follow.

What is the Role of an LTD Case Manager in your Claim?

A disability case manager’s role is to review your claim and determine whether the individual is eligible to receive benefits. The main task of an LTD case manager is to assess the employee’s functional limitations and capacities and compare them with their occupational demands. Ultimately, the question is whether the person meets the definition of disability as outlined in the policy.

After the insurer has received your application and supporting documents, a case manager will be assigned to your case to review your application and the additional information you’ve provided and make an assessment. If you’re missing any information, your case manager will reach out to gather whatever you may have missed. After all the information is in front of them, they will conduct a telephone or home interview to discuss your claim with you and answer any questions you have. Your case manager should make other arrangements if you are unable to communicate for any reason to review your claim with you or your power of attorney/legal representative.

During your assessment interview, your case manager will evaluate the following information:

The medical information provided
The demands of your occupation
How your ability to perform your job is impacted by your disability
How your ability to complete daily activities is affected by your disability

Your case manager will also likely:

Contact your employer
Contact your health care providers

Your case manager will often seek guidance from a medical specialist/consultant that works for the LTD Insurer. This Medical consultant normally conducts a paper review file to help the claims manager assess the medical conditions. Occasionally, the claims manager will send the claimant for an independent medical evaluation by a specialist hired by the insurance provider. This normally does not happen during the adjudication phase (before litigation) due to the associated cost.

The outcome of your assessment relies heavily on the supporting evidence that you provide with your claim. As much evidence as possible should be gathered before submitting your claim.

Providing the following documents can help your claim:

Official diagnosis
Physician statements
Employer statements
Treatment records
Medical test results
Medical scans and X-rays
Your statement about the effects of your disability on your daily life

After all the information has been gathered and the interviews are complete, your case manager will compare what they know and have collected with your group benefits contract. This is how they will determine your eligibility for LTD benefits.

After your claim is approved, your insurance company will provide you with a letter detailing the amount of your monthly benefit and the expected duration for which your LTD benefits claim will be paid. Your initial or retroactive (payments you are owed) payment might be included in this letter. If you already completed the direct deposit authorization section on your application, your LTD benefits will be deposited directly into your bank account. Your letter will also detail what to expect in the future from your LTD claim.

What Facts Should You Consider When Dealing with Your LTD Case Manager?

Your case manager must not communicate in an adversarial manner with you. A case manager must follow their duty to adjudicate the claim in good faith. This means that your case manager must provide a reliable and timely decision on your claim, and to adjudicate your claim on the merits. A case manager is required to provide clear, concise, and honest answers to any questions that have. Your case manager must also treat you with respect, fairness, and honesty.

In Canada, a duty of good faith requires insurance providers to act promptly and fairly when assessing claims. Breaching the duty of good faith can result in an award of extra-contractual damages such as damages for bad faith, or even punitive damages in rare cases. For punitive damages to be awarded, the court must find that the insurer acted unfairly and ‘delinquently’. The Court will have to find that the insurance company’s conduct was abhorrent.

If you think your case manager is breaching their duty of good faith, you may want to consider making a bad faith claim. Bad faith claims help deter insurance providers from acting in bad faith more often and exploiting the insured’s vulnerability. Compensation is paid to the insured for an insurer’s breach of that obligation. However, it is very hard to convince an LTD insurer that they have acted in good faith, and LTD Insurers normally refuse to pay any bad faith damages before trial.

In every claim, case managers conduct thorough interviews with the claimants and employers. They compare their findings from the interviews with the medical documentation they’ve been provided. Your case manager will explicitly explore your disability and how it disables you from working in your occupation. When submitting information, your employer’s, your doctor’s, and your own statement should clearly outline how your disability prevents you from returning to work, not just how it affects you daily.

Details about how your disability affects your daily life should also be included, but the effects of how your disability affects you outside of work must align with how it affects you at work. If you cannot walk up the stairs at work, you cannot walk up your stairs at home. Case managers often search for inconsistencies from the interviews, the medical reports, and their observations. They use these inconsistencies as a basis for you being untruthful about your disability, and any discrepancies may be used as the reason for denial.

Keeping your interview consistent with your application can prevent your case manager from digging deeper. Case managers often look for any reason they can to require further time to search, medical documents, or testing by in-house doctors. Keeping case managers off your case is not always easy; it is their job after all.

Our LTD lawyers want you to understand that your disability case manager is not on your team. Although it would be far more ethical otherwise, your case manager often works for the insurance company you’re insured by. It is the goal of case managers, like insurance, to not pay or pay as little benefits as possible to their claimants. Money is made by collecting premiums, not by paying out benefits.

Tips for dealing with your LTD case manager

The most important issue is to make sure they have the information they need. Make sure your doctors and treatment providers understand how important it is that they provide the information that the case manager needs to make a decision.

Treat the case manager with respect, at all times, even if it is not reciprocated. If you get upset, take a break and re-engage when you are able to.

If you have been approved for benefits, keep a good dialogue going. If you are going to be travelling or doing anything out of the ordinary, let the case manager know.

Keep notes of all your conversations with your insurance agency and case manager. In your notes include information like:

The date, time, and duration of your conversation
The person’s name you spoke to
What the discussion was about
Anything they said that stands out to you that seems unusual, offensive, shady, untrue, or otherwise troublesome

If you have problems reaching your case manager, leave a voicemail message for them to get back to you. If you don’t get a reply soon, try to contact them in other ways. Email is an important tool. We recommend that you communicate via email as much as possible, and that you send a summary of all conversations with the case manager by email. In your note, include the dates and times of all the points you’ve tried to contact them. Having them see that you’re diligently tracking delays in communication will put pressure on them to fulfill their duty to respond promptly.

If you’re having problems with your case manager, you can contact their superior. Speaking to their person responsible for overseeing your case manager could help correct their behavior, and there’s a small chance it could result in a new case manager being assigned to your claim. If you reach the supervisor’s voicemail, be sure to leave a message with the following details:

Your name
The reason you’re calling
Your claim number

Remember that if you decide to speak to the supervisor, it’s likely your claim manager will still be assigned to your case and the one making the decisions about your claim. Speaking to the supervisor is an option, but isn’t recommended unless you consider it necessary.

If you disagree with your case manager’s decision, you can appeal their decision or file a lawsuit. Hiring an experienced long-term disability lawyer is your best bet at reversing the insurance representative’s decision.

Should You Be Careful What You Tell Your Disability Case Manager?

Yes and no. It is important that you understand that a case manager will always act in the best interest of the insurance company that they work for. Already going through a difficult time, claimants are vulnerable people who need someone to confide in. Your case manager is the wrong person to talk to, no matter how much it seems like they care. Your interaction with the case manager should be professional and should be fact specific.

It is critical that you be truthful to the case manager. You cannot afford to hold things back in order to be strategic. Just focus on the key issues, which is proving to them why you are unable to work.

Get Help from a Long-Term Disability Lawyer at Valent Legal

If your case manager is hard to deal with, contacting an LTD lawyer can help you. The consequences of dealing with a case manager’s misconduct can be far more severe than one might think. The effects can be devastating and long-term, taking years to recover from emotional or financial distress, or unable to recover at all. Dealing with the additional stress could trigger or heighten a mental health issue. Similarly, that stress could aggravate physical medical problems and cause upset and setbacks to a claimant’s recovery.

To get help fighting the denial or termination of LTD benefits or the damaging behavior of your claim’s case manager, contact our long-term disability lawyers at Valent Legal.