It is important for us to work and provide for his family with dignity. Many Parkinson's patients work for many years despite the disease, but at a certain point, in cases of advanced disease, the ability to work and earn is significantly impaired. This is precisely why disability insurance exists, with the help of which the insured whose ability to work is impaired can continue to live with dignity by receiving insurance benefits every month. At the same time, the insured often encounter various rejections from the insurance companies who refuse to pay the monthly premiums. In this review, I will detail what loss of working capacity is, how you can exercise your rights within it, and what to do in the event that the insurance company decides to reject the claim.
What is disability insurance?
Quite a few people decide to purchase an insurance policy Work disability, lest a day come when they can no longer work due to their health condition and the insurance company will stand by them and pay the rewards they deserve, as a replacement for the insured's monthly income. In most cases, in order to receive monthly insurance benefits, the insured is required to lose 75% of his working capacity, when the claim is examined according to the policy he purchased (coverage for loss of working capacity for any "reasonable occupation" or specific position defined in the policy). In addition, there is an option to purchase an extension to the insurance coverage so that benefits will be given even in case of partial loss of working capacity, starting at a rate of 25%.
Of course, this is not a complete coverage against any reason that led to the loss of work capacity, so the policy conditions set restrictions, such as the use of alcohol or drugs, criminal acts or certain terrorist attacks.
It is important to understand that the examination of the claim is done on a class basis The functional disability that the insured has and not on a rate basis The medical disability. That is, while the medical disability relies on the deficiencies listed in the National Insurance regulations, the functional disability is examined in a broader perspective, and includes the age of the insured, the type of work and the actions he is required to perform within it, his work experience and more. Therefore, in most cases there is a gap, sometimes very substantial, between the medical disability and the functional one.
Is there a difference between the policies marketed by the various insurance companies?
Definitely. When a person is in a situation of loss of work capacity, his full insurance rights must be examined in a professional manner according to the policy he purchased. There are many different insurance policies. The difference can be expressed in the definition of the insurance case, the amount of the monthly compensation if the insured meets the definition of the insurance case, as well as many other conditions, including the caveats for the insurance case.
The main and perhaps the most important difference to be aware of lies precisely in the definition of the insurance case. That is, in the current insurance market you can find three main coverages for loss of working capacity, which differ from each other mainly in the definition of the insurance case. the first one, Policy for each occupation. This is a basic policy in which the insured's ability to engage in any occupation, either permanently or temporarily, is examined at a rate of at least 75%. Usually, an insured in this type of policy will be entitled to insurance benefits in exceptional circumstances and extremely difficult medical conditions if he cannot work at any job. This definition is quite reminiscent of the National Insurance definitions in the field of general disability [see also, an article published here on the website on the subject: General disability allowance].
The second, Policy according to reasonable occupation. As part of it, the insured's ability to engage in any other reasonable occupation (besides his work) is examined in accordance with his education, professional experience and training. Although the chance of receiving insurance benefits in accordance with this policy is higher than the chance in the policy for any occupation, however the current policy raises many obstacles, is subject to interpretation regarding the "reasonable occupation", and in fact is a breeding ground for rejections by the insurance companies. the third, Policy according to professional occupation. As part of it, the insured's ability to engage in the specific occupation he was engaged in before the loss of capacity is examined. In practice, this is the best insurance product that can be purchased to cover against a situation of loss of working capacity, since the definition of the insurance case is not subject to interpretation and the examination of the claim is done in a matter-of-fact way only regarding the specific occupation of the insured.
How do you file a claim?
If the insured believes that he is incapacitated and is actually unable to work as before, he must file a claim in accordance with the policy he purchased from the insurance company. The claim is submitted using a dedicated claim form that can be found on the insurance company's website or obtained by contacting the relevant company directly. As part of the claim form, you must fill in all the required details and specify the medical deficiencies the insured suffers from, and how they affect his earning capacity. Also, medical documentation must be attached to the claim form attesting to all functional limitations and difficulties. It will be clarified that there is no objection to attaching any medical certificate or opinion of a specialist doctor, who will assess the full extent of the deficiencies and determine the manner of their effect on the insured's ability to earn, in accordance with the relevant definition in the policy.
to work and receive insurance benefits - is it true?
A common question among many insureds concerns the possibility of an insured to continue working despite his limitations, and at the same time receive insurance benefits for loss of working capacity. The answer to this depends on several factors, among which the most important is the definition of the insurance case.
As a general rule, most of the insurance policies currently marketed in Israel by the various insurance corporations include conditions in the policy that prohibit the insured from working. Therefore, if the insured does do so, and has income from work, the insurance company can, under certain circumstances, refuse to pay the benefits and stop them immediately.
In this context, it is important to note that there are various insurance coverages, in some of which it is possible to purchase more extended coverage against loss of working capacity, in the form of partial loss of working capacity. That is, while full loss of working capacity is assessed according to the insured's inability to work and receive income to the extent of 75% at least, it is possible that partial loss of working capacity is assessed according to the insured's inability to work and receive income to the extent of 25% to 75%. So it is definitely possible that an insured with relevant coverage against partial loss of working capacity will continue to work despite his limitations. Moreover, in principle, there is no obstacle for an insured who claims to be completely incapacitated (as mentioned, an insured who unfortunately cannot work to the extent of 75%), from working and receiving income to an extent that does not exceed 25%, however this matter is subject to a broad medical interpretation through which a company can The insurance to reject the claim.
Common reasons for rejection
Many insured persons, including quite a few Parkinson's patients, often encounter rejections due to a wide variety of reasons in order to avoid paying insurance benefits for loss of working capacity. Below are the most common reasons used by the various insurance companies:
- The insured does not meet the definition of the insurance case - After the insured submits the claim, the insurance company has the right to have it examined by an expert doctor on its behalf. In many cases, the same doctor determines that the insured is not incapacitated as defined in the policy, or in other words the insurance company claims that the insured can work and is not entitled to insurance benefits. Because sometimes The insurance company's reasoning is based on a medical claim, after all, this is subject to interpretation and requires an in-depth medical investigation through expert doctors who are not interested in the case. In addition, it is important to clarify that the insurance company has many measures in place to examine a claim that comes before it, including the use of private investigators, so that many policyholders encounter In rejections based on the conduct of an undercover investigation on behalf of the insurance company, which makes findings that the insured is able to work and therefore does not meet the definition of the insurance case.
- non-disclosure - This is one of the most common claims used by insurance companies to avoid paying insurance benefits. In practice, the insurance company claims that at the time of joining the insurance, the insured did not reveal important medical data, which if they had been available to the insurance company in real time, the insured would not have been accepted for insurance at all, or at the very least, would not have been accepted under similar conditions. In this context, it should be noted that the initial burden of proving that the insured hid details at the time of joining, rests with the insurance company, including in the case where the insurance company believes that the insured had fraudulent intent.
- There is an exception for the insurance case - In the various insurance policies there are a number of exceptions to coverage, the so-called fine print, which can sometimes result in the claim being rejected. It will be noted that in accordance with the court's ruling, although the burden of proving that the insurance case exists rests with the insured, the burden of proof of the exception to the insurance case rests with the insurance company. In any case, the court examines each case according to its circumstances, therefore even if the exception exists, in many cases the court has the authority to order the insurance company to pay the insured the benefits to which he is entitled, including if the exception is unreasonable or it is proven that the exception was not properly explained when joining the insurance.
The insurance company rejected the claim - what to do?
First, the most important thing you should not do is get under pressure. In many cases, insurance companies use this strategy to avoid paying insurance benefits, even though according to all the data it seems that the insured is entitled to benefits, this means - a kind of "successful" method. Don't get excited about this. There are ways to deal with a rejection by the insurance company. In the first stage , it is important to insist on an orderly and clear rejection letter. After that, it is recommended to consult with an attorney who deals in the field, to examine the legal options available to the insured, including filing a legal claim against the insurance company.
Another thing that should be noted is a common mistake among many insureds, when after the rejection, they file an appeal against the insurance company's determinations, without first contacting the attorney. In this context, it should be known that according to the rule of the Supreme Court, the full reasons of the insurance company as part of the rejection letter , demarcate the dispute fence. That is, during the legal process (after filing a claim with the court) all defense claims raised by the insurance company cannot exceed the rejection letter. Filing an appeal as mentioned allows the insurance company to assert additional claims beyond the rejection letter, and to significantly improve its position.
From the above, it can be understood that the insurance companies have the upper hand. They have a solid financial and professional backing behind them, and they don't waste any means to achieve their goal. On the other hand, the simple insured is often required to deal with difficult situations, and sometimes makes mistakes that can damage his entitlement to the insurance benefits. Therefore, if you have lost your ability to work, it is recommended that you consult with an attorney knowledgeable in the field of insurance law to examine your eligibility and to receive the correct guidance regarding dealing with the insurance company.
