Category: Fine Print

Can your disability insurer offset your benefits because you are receiving other income?

Let’s say you become ill and can’t work anymore. Fortunately, you have disability insurance coverage through your employer. You apply and get awarded benefits. The policy says your benefits are two thirds of your salary. But the insurance company is paying you less. They say that they can subtract from your benefits any money you are collecting from Social Security Disability.

Can they do that? Like many insurance questions, it depends on the insurance policy fine print.

Most disability insurance policies provide an offset for so-called “other income” or “deducible income” you receive because of your disability. For instance, if your monthly disability insurance benefit would normally be $1,000, and you have $300 in deductible income, the disability insurance benefit is reduced to $700. What counts as deductible income that counts against your benefits depends on the wording of the insurance policy.

Deductible income often includes:

  • Social security disability payments;
  • Workers’ compensation payments;
  • Payments from other insurance policies; or
  • Payments from the person who inflicted the injuries that made you disabled (if a third party is responsible for your disability).

Moreover, disability insurance policies often require you to apply for potential sources of deductible income. For instance, your disability policy may require you to apply for Social Security Disability benefits.

The key is that the insurance company can’t deduct income that isn’t specifically listed in the policy. If you are receiving benefits under a disability insurance policy and the insurer tries to reduce your benefit because you are receiving other disability income, consult a lawyer to review the policy and make sure you know your rights.

When is it “too late” to make an insurance claim?

Let’s say the insurance company denies your claim. They don’t dispute you had a covered loss, but they say you missed a deadline buried in your insurance policy requiring you to notify them of the claim within a certain time. Can they do that?

The answer, often, is no. But the devil’s in the details.

Virtually all insurance claims involve important deadlines. For instance, there can be deadlines to tell your insurance company about the claim, to provide the insurer with documentation about the claim, to appeal the insurer’s denial of a claim, or to file a lawsuit. Which deadlines apply and the effect of missing them depend on the details like the insurance policy fine print and whether the policy is subject to ERISA.

Because the rules can vary and the consequences of missed deadlines can be draconian, it’s critical to consult an attorney to know your rights and obligations. Here are some general examples:

Deadlines to notify your insurer about the claim. Most insurance policies require you to notify the insurance company of your claim within a certain time period. Sometimes it’s “as soon as possible.” Sometimes’s it’s a specific date, for example, within one year of the loss.

The consequences of missing a claims notice deadline vary, but, often, the insurer cannot deny your claim just because you missed the deadline to give them notice. If you’re in Washington State, most insurers can’t deny claims just because you gave them late notice – the insurer has to prove that your delay in giving notice hurt the insurer’s ability to investigate your claim. If your delay in giving notice doesn’t stop the insurer from investigating your claim, the insurer typically can’t use the late notice as an excuse to deny coverage.

That means if your insurer denies your claim because you gave them late notice, there is a good chance you could challenge the denial. But beware – this rule does not apply to every insurance policy, especially policies subject to ERISA.

Deadlines to provide the insurer with information about the claim. Most insurance policies contain language requiring the policyholder to cooperate with the insurer by providing information about the claim. That could include, for example, allowing the insurer access to your home for a homeowner’s insurance claim, or providing the insurer medical records for a disability insurance claim.

Many insurance policies contain no specific deadline for you to provide this information. However, insurers will sometimes give you an arbitrary deadline to provide information they demand. They may tell you they will deny the claim if they don’t receive certain information by a specific date.

Similar to the claims-notice deadline, insurers typically have to prove that your delay in providing information harmed their investigation in order to deny coverage on this basis. But there are exceptions, and it’s important to bear in mind that policyholders have an obligation to cooperate with their insurers, which generally includes responding to reasonable requests for information. And, as a practical matter, looking obstructionist rarely helped anyone’s court case.

Deadlines to appeal the insurer’s denial of a claim. Many insurance policies provide that, if the company denies a claim, the policyholder can “appeal” the denial internally. An internal appeal means the company takes another look at the claim and any new evidence the policyholder submits.

Policyholders often have deadlines, sometimes just a few weeks, to submit an appeal. In some insurance policies, the appeal is voluntary, so failing to submit an appeal on time is unlikely to affect your rights. Other insurance policies – especially those governed by ERISA – make the appeal mandatory. That means missing the appeal deadline can cause you to permanently give up your right to contest the denial or seek insurance benefits.

Deadlines to file a lawsuit if your claim is denied. If it becomes necessary to go to court to fight an insurance claim denial, it’s critical to know the applicable statute of limitations, i.e., the deadline by which you have to file a lawsuit. Failing to file suit within the statute of limitations can mean you permanently lose the right to go to court. Most statutes of limitations are at least year from the date of loss. But there are important exceptions that depend on the details. For example, many homeowner’s insurance policies require you file suit within one year of the date of loss. Also, ERISA-governed insurance policies typically have far shorter deadlines to file suit – sometimes measured in days.

The upshot is that filing a late claim doesn’t make it a foregone conclusion that you lose your right to insurance benefits. If the insurance company denies your claim because you missed a deadline, there are often steps you can take to contest the denial and, potentially, obtain insurance benefits notwithstanding the missed deadline. But it’s critical to have an attorney review the facts and your insurance policy to make sure you know what deadlines apply and the consequences of missing any deadlines.

Court Ruling Emphasizes Tie Goes to the Policyholder When Interpreting Insurance Policies

Washington insurance law includes a principle that if an insurance policy is ambiguous, i.e., if it can reasonably be read in multiple ways, the court will adopt the reading that is most favorable to the policyholder.  This rule exists because insurance companies are sophisticated enough to draft their insurance policies the way they want, and have enough leverage over the consumer to offer their policies on a take it or leave it basis.  You typically can’t haggle with your insurance company over the fine print of the exclusions in your insurance policy.  Since the company can write the policy and has all the leverage compared to the policyholder, if the policy isn’t written clearly the court will read it to mean whatever a reasonable person buying insurance would expect as a matter of common sense.

The recent case Cheban v. State Farm found in favor of the policyholder by employing this rule.  Cheban made a claim under his auto insurance policy for damage to his car from an accident.  State Farm acknowledged there was coverage under Cheban’s auto policy’s Underinsured Motorist (UIM) coverage  But State Farm disputed whether the policy covered Cheban’s loss of use of his vehicle for the 47 days the car was being repaird in addition to the repair bills.

The insurance policy provided State Farm would pay “compensatory damages for property damage.”  State Farm argued this language limited State Farm’s obligation to only physical property damage, not loss of use.  Chaban argued the words “compensatory damages” expanded coverage beyond “property damage” to all resulting losses, including loss of use of the car while it was repaired.

The Washington Court of Appeals determined both State Farm’s and Cheban’s interpretations were reasonable.  Because the language was ambiguous, the court interpreted the policy consistent with Cheban’s expectations as the policyholder.  That meant Cheban was entitled to coverage for the loss of use while the car was repaired as well as the repair bill.

The Cheban v. State Farm decision is an important remind that ambiguous insurance policies will be construed in the policyholder’s favor.