I’ve Been Told it is “Too Late” For Me to Make a Claim For Health, Life, or Disability Benefits.  Is That Right?

The correct response is, “maybe, or maybe not, depending on the facts, and the state in which you reside.”

Insurance policies very often have time limits on the submission of a claim for benefits. In some states, those deadlines are VERY strictly construed, and once the deadline has passed, it does become “too late” to make a claim.

However, more than half of the states apply some form of an insurance rule called the “notice prejudice” doctrine.  Simply put, even if an insurance policy imposes a time limit for the submission of the claim, if certain rules are met, a claim can be submitted after the time limit if the late notice does not “prejudice” the insurance company’s ability to investigate the claim.  However, that is just a basic summary of the rule.  In the states that apply some form of the notice prejudice doctrine, its application differs from state to state.  In some states, the insured making the late claim must demonstrate a “good reason” for making a late claim.  In others, the burden falls on the insured to prove that no prejudice would be suffered by the insurance company because of the late claim submission.

That is different in California, where no good reason for the late claim is required, and it is the insurance company’s burden before rejecting a late claim to prove that the late submission of the claim has prejudiced its ability to investigate the claim (the most important legal case dealing with employer provided benefits and the Notice Prejudice Doctrine is the U.S. Supreme Court case of UNUM Life Ins. Co. of America v. Ward, 1999, 526 U.S. 358.)

Here is an example of how we have successfully challenged the rejection of a late claim

We were approached by a man in his late 40’s.  He had been a very successful engineer with the same company for 15 years, receiving stellar annual reviews . . . . for 14 years.  In his last year, his reviews reported very unsatisfactory work, and then he was terminated.  He sought new employment, and received many interviews, but no job offers.  He felt extremely fatigued and was having memory problems.  Unfortunately, he was diagnosed with multiple sclerosis.  He went to his former employer and inquired about receiving long term disability benefits, and was advised that it was too late, that he had to make the claim before he was terminated.

He then came to Kantor & Kantor.  We went to his employer’s insurance carrier and made the claim directly with the insurance company.  We received a slightly different response.  We were told that if he was terminated because he was disabled, he had a right to receive benefits, but since there was no way of knowing if that was the case, his claim could not be paid.

We were convinced the insurance company was wrong and set out to prove it.  We obtained all 15 years, of his performance reviews, the 14 great ones, and the last review, showing his poor performance.  We noted the last review spoke of his forgetfulness and his seeming to be too tired to perform his regular duties as an engineer.  We then took the reviews to his neurologist, who had diagnosed his Multiple Sclerosis almost two years AFTER he had been terminated.  The neurologist was eager to help, and wrote a letter explaining that Multiple Sclerosis symptoms appear over time, and he was able to offer his opinion, with a high degree of medical certainty, that our client was suffering from the symptoms of M.S. at the time he was terminated, and that the fatigue and memory loss were absolutely associated with the M.S. diagnosis.

We also provided the insurance company with proof that our client had sought new employment, and based on his resume, had gone on many in person interviews, but obtained no offers of employment.  His in-person appearance and communication skills had so deteriorated, that no employer found him to be an acceptable candidate.

We presented all this information to the insurance carrier and were prepared to take it to a Court if necessary.   But it wasn’t.  The insurance carrier, within two weeks, had studied the information we provided, and came to the only reasonable conclusion:  At the time our client had been terminated, he was suffering from the symptoms of M.S., and it was because of those symptoms that he could not do his job.  His claim was paid.  And here we are 15 years later and his claim is still being paid.

Lesson to be Learned

The lesson here is NEVER take “NO, your claim is too late” as being correct without doing further investigation.   Find an attorney in your state who can advise you if you have rights that your employer, or your insurance company are not telling you.

For more information on your health, life or disability insurance claim, please do not hesitate to contact Kantor & Kantor for a no-cost consultation at (800) 446-7529 or use our online contact form.

 

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