Hey @Disco,
My name is Merl and I’m a member of the Modsupport Team here on Ben’s Friends.
I have had the ‘joy’ (NOT) of trying and eventually succeeding in obtaining both SSDI and Total Permanent Disability (TPD) cover due to a traumatic brain injury BUT I must admit neither were an easy process at all.
Now, I’m in Australia, so some of the rules, processes and criteria will vary from jurisdiction to jurisdiction but I will try to explain some the convoluted journey I had to take in gaining both SSDI and TPD.
I was working fulltime, plus regularly (Every week) doing overtime, over and above my contracted hours. My contract was for 25hrs/week, but my usual regular hours were 40-50hrs/week. As part of my TPD cover I also had income protection insurance component. I was admitted to hospital for surgery on a brain tumour. My plan was surgery, recovery, then back to work and I thought ‘At most I might be off work for a month’ but after a month I still was not in any condition to be working and started the process of claiming income protection.
The insurer required all sorts of paperwork, everything from a birth certificate to tax returns and letters from my employer, all of which I provided. The coverage was for 80% of my pre illness income. The insurer tried to say it was only for 80% of the contract hours and not 80% of actual income I objected to this as my premiums were worked out as a % of total income, not a % of contract hrs. The policy was purchased via my superannuation, so I contacted the super company and they agreed if the premium was calculated on total income, the insurance was for total income too. The super company contacted the insurer on my behalf and the insurer reluctantly paid the appropriate income protection amount.
Here in Australia, most income protection only lasts for 2 yrs. In that time I’d repeatedly attempted to return to work, without success. I’d seen all sorts of drs/specialists/wizards trying to find answers or remedies or treatments to get myself back to my former self and back to work. I did all of this by myself, without direction from the insurer. I then applied for the TPD component and the insurer started putting up road blocks, questioning my paperwork, wanting certified original copies of EVERYTHING, wanting me to go and see more dr’s of their choosing. Again, I objected, I already had such reports from equivalently qualified specialists, why did I have to ‘re-invent the wheel’ all over again? They wanted ‘new’ reports. This all had to be done on their timetable or the claim would be dropped. So back on the roundabout running around seeing dr’s.
By this time I’d had enough of the ‘Fun’n’Games’ the insurer wanted to play. This wasn’t a game, this was my life and I was exhausted. The insurer had made the whole process so difficult at every step, they were hoping I’d decide to just give up on the claim, they were wrong. I told the assessor I’d had enough of their games and was now getting the lawyers involved. Well, didn’t that get a reaction "Ohh no, no don’t do that’ She said. “Too late” came my response. I contacted a lawyer via a ‘No Win, No Fee’ basis and after looking at my case they agreed to take it on. Involving the lawyers was the best thing I could have done (I only wish I’d done so earlier), they took over the whole claim process. I was required to attend 2 medical assessments, one with a psychiatrist and one with a professor of neurology. Being that the professor was employed by the insurer I thought the claim would be rejected outright, but to my surprise he agreed with my claim (In fact his direct words to me were ‘You’re screwed’ which was a little shocking, even if honest). It took 12 months from my initial TPD claim to obtain the payout I was due. In that time I had investigators watching me, watching my house, whose coming and going. Parked up the road. Watching. Speaking to neighbours. Looking for any excuse not to pay. Some of these companies are NOT nice people.
In that 12 month period I also tried to claim the Australian equivalent of SSDI. They asked for reports from the most recent neurologist I’d seen. This particular neuro told me at the appointment that I’d have to pay $1500 cash for him to support the claim, which I queried as to me it sounded like a bribe, I refused to pay. But as he was the ‘Most recent’ I had to include his details. My claim was rejected and I appealed the rejection. It went to court, where the neurologist was present and again the claim was rejected.
By this time the TPD claim had been approved and I contacted the lawyer I’d used, asking for a copy of the Professor’s report. With this report I re-applied for SSDI and it was finally approved.
My advice:- GET YOURSELF A LAWYER!!! Someone with experience with insurers. Some of these insurers can be nasty, they can have you running from one dr to the next, stretching the whole process for longer and longer
DOCUMENT EVERYTHING!!! Copy every form, document and report. If you see a dr, get a report. If they send you for a scan get a report.
RECORD EVERYTHING!!! If you see a dr and they refer you on to a specialist, record the date, the time, the name of the specialist and their specialization. If they make a recommendation, record that too.
FOLLOW THROUGH WITH EVERY RECOMMENDATION!!! Eliminate every option/suggestion/idea open to you.
Now, you may ask ‘But why?’ to all of this and here’s why:
I started my journey looking for answers. I wasn’t concerned about the insurance, my plan was to return to work, so I didn’t do any of the recording/file keeping. This was all going to be ‘Fixed’ so there was no need.
My PCP at the time ran me through all sorts of test and scans, all sorts of medications, all sorts of ‘alternative’ therapies. But none of them were my ‘key’. He referred me onto a private neurologist. The neurologist wanted to do exactly the same tests and scans, trial the same meds and suggested the same therapies. When I told the neuro I’d already done all of this he said “Where are the reports?” I didn’t have them, so I had to do them all again (this time keeping copies for myself).
Some of the suggested treatments I refused, thinking ‘Well, that’s not going to help…’ or ‘That’s not going to work…’ and in doing so disadvantaged myself. The dr’s kept using that as a refusal point, ‘patient refuses treatment option ‘X’…’. Many policies actually stated “Must have exhausted every avenue of treatment” or words to that effect. So that’s exactly what I did. If a dr had an idea, I wanted to hear it, trial it. They didn’t work for me. But, no Dr could say I refused.
Now, by having it all documented when a dr or a health professional or insurer wants me try an option. I can prove to them, with documentation, ‘Already been there, Already done that’. It cuts off any avenue for them to reject a claim. They like to reject.
By having it all documented you are showing that you are being proactive in your own care.
I cannot say it loud enough:
GET YOURSELF A LAWYER!!! one who deals with this kind of thing. Yes, it did cost me legal fees but it was less than 10% of my payout figure. What the lawyer DID do was saved what little sanity I had left after trying to deal with the insurer by myself. Their aim is to wear you down and they do it so well. They know how to play the game. What you need is someone who already knows their games and can pushback. Get a lawyer.
All of that above is my experiences in dealing with the systems here in Australia and some of the rules here have changed since my claim. Now the impairment levels are much greater to obtain a payout, so you’ll need to investigate YOUR policy for YOUR rules. TODAY. to know where you stand now.
If we, at Ben’s Friends, can assist in anyway. Please ask. We may not have all of the answers, but if we have the knowledge/information the members here are more than willing to share. So, Ask.
(SORRY, That’s all a bit l.o.n.g. But those are my experiences trying to navigate the system)
Merl from the Modsupport Team.
