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TexLaw
TexLaw, Attorney
Category: Legal
Satisfied Customers: 4196
Experience:  Lead trial/International commercial attorney licensed 11 yrs
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My husband has been receiving total disability benefits from

Customer Question

My husband has been receiving total disability benefits from a policy he personally paid into for 16 years. In the policy it states maximum benefit period .. Your lifetime if disability commences before your 55 th birthday. His total disability - a brain stem stroke happened when he was 51. At the time that the disability claim was approved his underwriter told him that they do not even write these types of policies anymore, but that he qualified based on his injuries and 16 years of paying to keep the policy in force all those years out of pocket, instead from the GI practice. He was a GI dr and surgeon. However the stroke left him with depth of field problems among many other health issues that would preclude him from performing his duties as described and needed for the practice.

This past month we received a letter stating the insurance co was in the process of updating their medical files on him.They would appreciate if we would complete the enclosed information for, regarding all the medical history in the past 5 years and not just on his claim condition. In order for medical providers to release records a current dated authorization is required. The latest one they have on record was 5 months ago by his annual attending physician. Then in the authorization form it includes the following: entire patients medical record, non medical information about him, education, occupation, employment history earnings, finances, eligibility for other benefits. Social security info including detailed info regarding earnings for up to 10 years and a summary record for total earnings . He is collecting no other disability benefits. He is not collecting social security of any kind deferring it till the age of 70. He is now 65. Our understanding is that the request for tax records is a violation of ones constitutional rights to privacy. The monthly benefit amount is fixed and was based on his 3 highest earning years back when the disability happened in 1997. The definition of total disability is if he is not able to do the substantial material duties of his regular occupation , such as endoscopy surgery at the time of the disability. Does the insurance company have the right to ask for items other than those medically related? I i.e. tax returns employment status education finances. Employment history and social security info? What are my husbands rights to all this confidential info? Are they on a fishing expedition to drop him, and should we seek counsel of a disability insurance attorney?
Submitted: 2 years ago.
Category: Legal
Expert:  TexLaw replied 2 years ago.
Hi,

Thank you for your question.

Your tax information is protected by your constitutional rights to privacy unless that right is abrogated by contract (i.e., you give someone permission to see it), or if you put your income at issue in an adversarial legal proceeding.

Under a disability policy such as the one you are referring to, the policy requires that you cooperate with them in connection with any claim submitted. Further, because the nature of the relationship between insured and insurer is one of contract, the company is not in an adversarial position to your husband that would trigger a constitutional privacy protection. In other words, the insurance policy provides the insurance company with permission to look into this type of information.

The type of information that the insurance company is requesting is related to the nature of the disability claim. A disability claim is not only associated with the actual medical disability suffered by your husband, but also concerns the calculation of benefits due to him which is based in part on his prior income. Thus, they likely have a legitimate interest in obtaining the information. Also, you do not want to endanger an assertion by the insurance company that you have failed to cooperate, which will trigger their rights to terminate the benefits.

That being said, the insurance company is definitely undertaking a review of your husband's claim. They are looking for any information that will allow them to reduce the benefits. Unfortunately, they are most likely entitled to this information pursuant to the insurance policy. If there is any information out there that would trigger a reduction, such as a miscalculation of his earnings, then the insurance company is entitled through the policy to be able to review the information to make a determination.

You will need to comply with the waiver request. If the insurance company decides to change your benefits based on any of the information provided, then you will want to contact a disability insurance attorney to protest the negative finding on your claim. However, at this point, you are required to comply with the information request.

-ZDN
TexLaw, Attorney
Category: Legal
Satisfied Customers: 4196
Experience: Lead trial/International commercial attorney licensed 11 yrs
TexLaw and 17 other Legal Specialists are ready to help you
Customer: replied 2 years ago.
The tax info they are requesting is forvthevpast 10 years. Well after the disability claim was accepted and processed. The amount he receives was based on his 3 highest years prior to te disability.

You mean they can still look at what Hess made in the past decade after he had to recreate himself after he gt over the major depression of having his career taken away from him by a stoke.. 15 years worth of medical training which he could no longer perform? Thank you
Expert:  TexLaw replied 2 years ago.
The right to disability benefits under an insurance policy turns on whether the individual is disabled. If an insured became disabled in one line of work, but then retrained and was able to do a different type of work, then the disability benefits may be reduced under the policy as the person is no longer considered disabled. In your husbands case, if he has retrained himself and started earning money in a different profession, there is the possibility that this would affect the right to continued benefits. There is also the possibility that the insurance company could attempt a fraud claim against you.

If your taxes will show that your husband was earning money from a different source of work, then you definitely need to retain counsel. If there is information in the tax record that could hurt your right to the disability benefits or could trigger an insurance fraud claim, you will want to resist disclosing that information or limiting the fashion in which it is disclosed. I'm not trying to say that there is a fraud claim against youas obviously I don't have the full picture of what is going on, but you need to take these things into consideration.

That being said, the insurance company is entitled to review your husband's status as disabled by looking at this type of information. An attempt to prevent the disclosure of the information needs to be done very very carefully so as not to draw any unwanted attention or trigger the non-cooperation clause which will cancel the benefits.

-ZDN
Customer: replied 2 years ago.
This is a very special type of law. We will retain a disability insurance policy attorney. The policy was written back in the 70 s and is tax free since it was paid out of pocket by the individual and not the group. My hunch is that they will reduce benefits to residual, offer a settlement or try to claim him as whole and drop him altogether. In any case scenario, legal counsel should best be obtained. Thank you.
Expert:  TexLaw replied 2 years ago.
I agree. This type of policy is indeed very rare, so I think your decision to retain an attorney to handle the matter from here on out and give you specific legal analysis of your duties under the insurance policy is very wise.

I wish you good luck and hope that this turns out in your favor.

Best Regards,
ZDN

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