OT: Insurance company surveillance

[Guest guest]

Interesting article. Not completely accurate, but it's close. I thought this

would be helpful to any of our members who are trying to get disability or

workers' comp benefits.

Surveillance Techniques in the Disability Insurance Industry by E. Nee,

HIA, DIA, DHP Published in the Lyme Times Spring 2006 Issue #44

Disability

insurance claims adjusters are trained to locate what is referred to as

" red flags " within the claim file documentation you provided to the

insurance company in support of your claim. Examples of " red flags "

are: inconsistent information provided to the insurance company, or, in

some cases simply a " gut feeling " of suspicion about the claim. Most

disability claims are investigated by using surveillance, either as a

" tag surveillance " for an Independent Medical Evaluatin (IME), or very

early (or late) risk management intervention.

The

actual questions provided to field surveillance representatives are

often the result of the degree of expertise and experience the claims

adjuster has for identifying what is referred to as " inaccurate,

inconsistent, and suspicious information. " Self-reported impairments

such as fibromyalgia, CFS (Chronic Fatigue Syndrome), Lyme disease, RSD

(Reflex Sympathetic Dystrophy, MS, headaches, back complaints, vertigo,

dizziness, fatigue, and other " self-reported claims are particularly

subject to surveillance referrals.

The claims

adjuster may request a detailed activity data base check. This includes

information regarding your driving record, properties owned, licenses

held, court actions, bankruptcies, credit rating, marriages, divorces,

pharmacy records, records of children (with the same surname), criminal

records, unemployment history, child support records, court records,

employers, military records, aliases --well, you get the idea. This

data base check tells your insurance company more about you than even

you may know.

Some disability insurers now have

the ability to research the number of frequent flyer miles you have,

golf or country club memberships, tee times, exercise club facilities,

etc. As a general rule, I always tell my clients to assume the

insurance company knows everything you do.

Remember

the authorization release you signed? Your disability carrier may use

this release to perform a FICA check to see if you have been working

and not telling the insurance company. Since earnins from employment

are an offset (reduction) to benefits, the insurance company has a

vested interest in making sure you have reported all your employment

earnings.

Therefore, employers are contacted,

as well as your neighbors, friends, or co-workers. If you ever thought

your privacy was being invaded, this is certainly it, although almost

every disability carrier claims they have a right to surveillance to

uncover potential insurance fraud. Insurance fraud statements are

written into nearly all new policies.

Next, the

claims adjuster may ask the field investigator to tape you on video,

producing a visual CD/DVD/Digital record of your activity for three

days. If the surveillance team does not locate you immediately, they

may use a ruse of some kind to call you at home to determine your

whereabouts.

The caller may identify himself as

a courier for the " US Purchasing " company, or another type of delivery

service. They usually ask questions like, " Is there another location

where we may reach you today? " Or, " If you aren't home, where can we

get in touch with you? " Obviously, the investigators are attempting to

find out if you are working or going to another location on a regular

basis.

The surveillance team is highly skilled

in evasion surveillance, very rarely blowing their cover, since the

majority of insureds do not suspect the insurance company of such

activity.

Although by law the surveillance team

is required to obtain neighbors' permission to watch you if they must

go onto adjoining private property, they frequently do not. Always be

aware of following cars or persons sitting in cars near your home or

property. Some surveillance teams notify the local police of their

surveillance activity to avoid police response and intervention, if

spotted. The average time frame for surveillance is 3-5 days, which may

cost the insurance company $2,000-$5,000. In addition to the CD/DVD

provided to the claims adjuster, an hour-by-hour written report is also

sent as a permanent part of your disability claim. Most surveillance

teams will notify the claims adjuster by phone and discuss an initial

report before and after the actual DVD arrives.

Physicians

and as many as 25 person (including management) attending a roundtable

or " huddle " discussion will review the surveillance report and DVD

provided to the claims adjuster. A copy is sent to your attending

physician for comment. If your physical activities are inconsistent

with your diagnosis and reported activity, your physician may contact

the insurance company and change his/her medical opinion, releasing you

to return to work. This surveillance record becomes a permanent part of

your claim file documentation and follows your claim, even to the

appeals level or before a judge. Physicans can often be easily

persuaded to release you to return to work activity when faced with a

persistent insurance representative and convincing surveillance.

The

disability insurance company's internal protocols prevent the claims'

adjuster from providing you a copy of the surveillance report until a

final liability determination is made. If your claim is denied, all

documents related to any surveillance activity must be provided to you

along with your claim file.

A surveillance

tactic commonly used by disability insurers is called " tag

surveillance. " If you have been asked to submit to an IME, the process

is as follows: The claims adjuster will call you a day or two before

the examination and question you in detail concerning your functional

activity and medical status. A surveillance team is assigned to observe

you on video a day before, the day of, and the day after the IME. The

purpose of " tag surveillance " is to actually " catch " you engaged in

activities you may have said you couldn't perform before the IME.

Inconsistent reportiing of physical activity can be used adversely if

the disability insurer is able to record you engaged in activities you

previously reported you couldn't do.

Remember,

no disability claim can be denied solely on the basis of surveillance,

since there is no such contractual provision in your policy which

allows disability insurers to do so legally. Surveillance results are

strictly " out of contract. " What the disability carrier will do,

however, is submit the surveillance DVD to your treating physician with

a request to reconsider their previous certification of your inability

to perform productive work. If the physician agrees and releases you to

return to work, your claim will be denied. In my experience about half

of the physicians presented with visual evidence actually do reverse

their disability certification and sign releases for work. Visual

surveillance is VERY CONVINCING!

Be cautious.

The disability insurer, and its outsourced agents have spent many years

developing surveillance methods of locating database sources of

information reflecting negatively on your credibility as a claimant.

Management trains all claims adjuster in the identification of " red

flags " , and no insured is immune from surveillance if their monthly

benefit is high enough to support the cost of surveillance.

What

does this mean? If you expected to receive a monthly benefit ranging

from $100 to, say, $2,000 per month, you may be less likely to be

surveilled, although not immune from it at any point in the claim

history. As stated above, your monthly benefit would need to be high

enough to warrant the cost of surveillance.

In

conclusion, be mindful of the authorizations you sign for any insurance

company and exercise extreme caution how you communicate with

representatives identifying themselves as claims specialists. Be aware

of unusual people in your neighborhood; ask neighbors to tell you if

anyone has been inquiring about you. If you identify someone following

you and feel uncomfortable, notify your local police department and ask

for an officer to terminate the surveillance.

Assume

all public records about you have been obtained by the insurance

company. And, finally, talk to your doctor candidly in advance

regarding your impairment and restrictions from work. Discuss the

possibility of surveillance by the insurance company in advance, and

continue to have open and honest conversations with all your treating

physicians. As your physician to notify you immediately of any

surveillance information or additional requests for medical information

received.

Because you have submitted a claim

for disability benefits, your insurance company will scrutinize your

past and current activities at a time when you are not feeling your

best. If at any time you are not feeling well enough to communicate

with your claims adjuster, ask to reschedule the call and plan your

conversation in advance. Obtain a copy of your policy, and read it

carefully. Knowing your rights under the policy provisions can mean the

difference between benefits denied, and benefits paid.

Should

you feel scared, intimidated, or threatened by a surveillance team,

notify your local police department. At that time, the surveillance

will have been identified and, for all intents and purposes, the

activity is over. If you feel safe to approach a person who is watching

you, you may do so and request the termination of the surveillance.

Once the cover is blown, the activity is generally terminated.

Remember,

surveillance is used most often to identify " inconsistencies of

reported activity. " If you tell the insurance company you cannot lift

anything and are subsequently observed lifting feed sacks into the

barn, chances are your claim will be denied. Again, this is a very good

incentive for being honest with insurance company about your activities.

http://www.disabilityclaimssolutions.com/articles.html