If you’re the holder of an individual or group long term disability insurance policy through the Equitable insurance company, you’re luckier than many claimants – these policies are generally thorough and high-quality, offering an expansive definition of disability and fairly few limitations as compared to other long term disability insurance policies. But proving to Equitable and its third party claims investigator that you’re entitled to disability benefits can still seem like an uphill battle for many claimants. What should disability claimants know about the disability insurance claim approval process and what they can expect from Equitable?
GREG DELL: Hi. I’m Greg Dell here with attorney Cesar Gavidia. And we are going to discuss the Equitable insurance company today. And specifically, we’re going to discuss how they handle long-term disability insurance claims. Now, Cesar, we know Equitable is a unique disability claim because of the fact that they commonly use a third-party administrator, known as Disability Management Services, to administer their claims. What’s been your experience when working with claims from the Equitable?
CESAR GAVIDIA: So when you’re dealing with Equitable, you’re naturally dealing with, as you said, DMS as well. Well, you’re dealing with DMS primarily. Equitable, obviously being the underwriter and the policy issuer, doesn’t do the administrative handling of the claims themselves. So Disability Management Services is contracted to do that for them. They’ll have a group of disability insurance specialists, claims representatives who, once you submit your claim, this will go to a specific representative.
They’ll begin by probably asking you to complete very specific forms, having your doctor complete very specific forms, often referred to as “attending physician statements.” They’re going to request all of the extent of all your medical records, possibly your entire medical history. It depends. These policies are often individual disability insurance policies, so we’re not often dealing with preexisting condition issues or anything like that. So they often limit the request to the pertinent medical records that they need.
GREG DELL: OK, now, Equitable is their branded name now that they’ve switched to recently. They used to be known as Axa Equitable, which is A-X-A. And a lot of these policies were written 15, 20, even 30 years ago. And a lot of the claimants are physicians, attorneys, individual business owners that bought their policies from an independent agent.
You mention that these are individual disability policies. Talk for a minute about why it’s an advantage for the claimant that they have an individual disability policy versus one that was sold by the employer. Because Equitable really doesn’t sell a group disability product that we’ve come across.
CESAR GAVIDIA: Right. So when you have an individual disability insurance policy, I guess, as opposed to a group insurance policy, you have to remember this is often a policy that you purchased, you paid for, and you bargained for. It’s not one that some association or your employer went out, and sought out, and purchased, and provided for its employees. This is one that was kind of specif– especially or specifically customized for you.
GREG DELL: Right. So it’s a contract.
CESAR GAVIDIA: It’s a contract. And it is often specific to your occupation, whatever it is that you’re doing at that specific point in time that you become disabled. And that’s really, really important because most other types of disability policies, like group insurance policies, employee-provided disability policies, association policies, often don’t have that special, focused in, true own-occupation disability language for the extent of the disability claim like you would find in an individual disability insurance product or policy, like the Axa Equitable– or like the Axa Equitable policies.
GREG DELL: So I want to go through and talk about the top, say, the top five advantages to having an Equitable individual policy versus what you would not get when it comes to filing a claim or a lawsuit with a ERISA-governed policy. So what’s the first thing that comes to your mind in terms of an advantage of having an individual Equitable disability policy.
CESAR GAVIDIA: You mentioned it. You’re dealing with a specific contract. So naturally, you’re dealing with a breach-of-contract claim, not a violation of ERISA claim or failure to pay benefits claim that you would have in an employee benefit provided policy situation. What that means is that you could avail yourself or be– or basically have these protective rights, such as bad faith laws and special insurance laws that protect you in your particular state, because of this individual disability insurance policy that you purchased that’s specific to you.
GREG DELL: OK, so you mentioned two things. The third thing that comes to my mind which is essential is what I call “the ability to drop the hammer on them at any time,” which means that you can file a lawsuit.
CESAR GAVIDIA: Right.
GREG DELL: And by filing, not just the ability to file a lawsuit because you can file a lawsuit in either one of these, but you don’t have to go through an administrative remedy where you have to file an appeal, which is a huge advantage, I believe. Number two, when you do file a lawsuit, when you’re ready, you can file it in state or federal court depending upon which one we think is better.
Number three, you’re going to get a jury trial. And I think having a jury trial is a tremendous advantage because of the fact that you’re not stuck with the opinion of just the judge. And what we’ve talked about all the time with the arbitrary and capricious standard versus a de novo review standard, you don’t have to deal with any of that. You are going to get your day in court.
And when you have a ERISA government policy and not this Equitable-type private policy, you don’t really get a full day in court. You don’t get a jury, six members of the community who are supposed to be your peers, whatever that may be. But you don’t get your chance to even speak. So–
CESAR GAVIDIA: Right. Now, you also have to remember, and we know this because we were in– we’re in court all of the time. We’re litigating all of the time. We’ve been to trials. Very few cases actually make it to the trial phase of litigation. So most cases, and I think the statistic is in nine– in the 90th percentile for civil dis– for civil claims, for civil lawsuits.
So 90-something percent of claims settle out, and they settle out based on this risk assessment that the insurance companies do, that the parties do. Really, both sides have to do this risk assessment. But insurance companies see things in dollars and cents, and they see the risk that they have, the exposure that they potentially have, and that’s exponentially higher in a breach-of-contract situation dealing with an individual disability insurance policy versus an ERISA-governed claim.
GREG DELL: Right. So what you’re essentially saying is you’re going to get a lot more value out of an individual disability policy–
CESAR GAVIDIA: Absolutely.
GREG DELL: –than you would out of a group policy. Now, everyone who calls us, for the most part– and we encourage you to call us for a free consultation if you’re watching this video– one of the first things they’re going to say is, what do you think about the chances of me winning your case? And that’s always a loaded question. And but why are we limited initially in terms of telling someone, do we think you can win or not?
CESAR GAVIDIA: Every case is dictated by a number of things. But primarily, we’re looking at the value of the policy through the course of the claim, through the life of the policy, let’s call it. And that could be limited to age 65, or it could be– go as far as for a lifetime depending on the policy. And many of these Axa Equitable policies have these lifetime insurance or disability riders that pay you for lifetime if you become totally disabled before a certain age.
GREG DELL: OK, well, first thing– I just want to stop you there– is that, first of all, when they say, how good is my case? First of all, I’d say, well, you have an Equitable policy. That puts you ahead of most of the other people because, usually, they’re very good policies from my experience.
CESAR GAVIDIA: Right.
GREG DELL: They have very favorable policy language. They have favorable terms. The definition of disability is usually very good. They have very few limitations, such as mental nervous limitations or musculoskeletal limitations. So you’re in a good starting point. What’s the next thing that’s important for someone who wants to go to a claim with Equitable?
CESAR GAVIDIA: Then you’re obviously considering, in terms of your odds or your likelihood to succeed, is the facts. Every case is dictated and determined based on the facts. The value is inherently tied to the facts of your case and the medical support in your case.
It doesn’t always mean– because the insurance companies throw around these terms, objective versus subjective. It doesn’t always mean that you have to have the objective evidence. I mean, we tried a case specifically on that very issue, and we prevailed when there was very little objective evidence. You know?
GREG DELL: Right.
CESAR GAVIDIA: So but there’s so many things that go into it, the credibility of the client, how sympathetic or empathetic they come across. Because if you’re going to have six people basically judging you, in many ways, they have to like you, and they have to like your lawyers. And that could dictate the value.
I mean, there’s so many of these exponential things that could affect the value of the case. But lawyers, such as ourselves, and insurance companies, we know how to do these kind of risk assessments and make these determinations to decide, what is the best thing for you to do in your case?
GREG DELL: So for a person who’s contacting us, what do you need to review to determine whether or not you think they have a reasonable chance of getting their claim approved if they’re considering applying or even overturned if they’ve already been denied?
CESAR GAVIDIA: Well, the first thing we do is obviously have that initial consultation with the claimant. All right, that’s very important. I often spend– it could be as long as an hour or longer just in my initial consultation with them, understanding who they are, what their claim stems from, what the medical issues are that they’re suffering from, who the doctors they’re seeing are, how many specialists they’ve been to, how frequently they’re seeing these doctors, what kind of medications they’re taking. What kind of limitations and restrictions are these doctors imposing on them? So that’s a very important interview process as much for the client as it is for us.
GREG DELL: Right.
CESAR GAVIDIA: The second thing we do, assuming that once we jump aboard and we’re hired, we have to look through the claim file. We have to look through the denial if– well, assuming it gets to that stage where you were asking before.
GREG DELL: Assuming it’s in denial, yeah.
CESAR GAVIDIA: But we have to look through all the medical records. We have to understand how well this question of limitations and inability to perform your own occupation is documented within this volume of medical records you have.
GREG DELL: OK, and then I think the other thing that’s important is understanding what the client’s goals are, meaning like, what do you want to do? Are you not able to do any work at all? Are you possibly a surgeon who now wants to do a family practice or just not do surgery anymore but still see patients? Or were you a business owner who was doing some kind of medium-duty or light-duty job, and now you want to do just an executive, sedentary-type job?
So there’s a lot of flexibility to discuss in terms of what the person wants to get out of the policy and how long they think they’re going to need this policy. Because most of the people calling us don’t want to be on disability because they’re probably making more working than they are going to collect on disability. So we have to discuss those lifestyle things.
And then the other thing along the lines is, what else is the person doing when they’re not working? And that goes to what you were saying about the credibility. Because a lot of complaints with someone who has disability is their subjective complaints of pain that can’t be measured by anything because there’s no machine that measures someone’s pain.
So the disability company is going to look at, what does that person do? Well, they may not be able to work. Are they still a golfer? Do they still like to go surfing? Do they like to go on a boat? Do they fish? Do they coach softball? What are they doing that may be inconsistent?
CESAR GAVIDIA: And you’ve mentioned scenarios that we’ve encountered–
GREG DELL: Yeah.
CESAR GAVIDIA: –at some point in one of those– right.
GREG DELL: Well, with every single person. I think, remember, we had the world judo champion–
CESAR GAVIDIA: Had the world judo champion.
GREG DELL: –who was a chiropractor but could still compete in that.
CESAR GAVIDIA: We’ve had surfers. We’ve had–
GREG DELL: That might have even been an Equitable case, but I don’t remember. But the point is we have to understand what the claimant’s doing so that we can determine, well, it’s not just you’re saying you can’t do your work. But what else are you doing in your life so that we can protect you in terms of making the claim continue into the future?
CESAR GAVIDIA: And it’s not that you have to necessarily stop living your life and stop doing these things that you enjoy doing, whether it’s golf, or boating, or fishing, or judo. But there are going to be questions that are– that come up with the insurance company, and those questions need to be addressed and responded to in the correct way.
GREG DELL: And so the last area people say is, well, what do you think about Equitable in terms of their reasonableness in reviewing claim? And the only thing I could think about in that is comparing them to the other companies. And I would clearly say that they’re one of the more reasonable companies.
And dealing with Disability Management Services, I always talk about this culture of a company. And I find that they have more of a culture of looking for a reason to pay the claim as opposed to looking for reasons to deny the claim has been my experience with Disability Management. They also have long-term employees that have been there for a while. They’re very experienced.
But with very experienced claims people come challenges that you know about, that they are going to make sure that every I is dotted and every T is crossed. And they know exactly what needs to be there. And if there’s something specifically missing that’s a reasonable item that’s missing or a weakness in the claim, DMS is going to pick up on it. Has that been your experience?
CESAR GAVIDIA: Yeah, absolutely.
GREG DELL: All right, so in summary of everything we talked about in terms of Equitable, if you have a long-term disability claim with Equitable, no matter what stage you’re at, whether you’re considering filing for your claim, you’re on claim now, and you’re tired of dealing with Equitable, or you’re worried you’re going to get denied, or you’ve been denied, we’ve handled every single scenario. We can help you with any of the scenarios related to your claim with Equitable.
We represent claimants all over the country. Whether you contact Caesar, or myself, or any of the lawyers on our team, we’re always going to offer you a free initial consultation and try to let you know right away whether or not we can help you. We look forward to the opportunity to speak with you.
As you’ve read, handling an Equitable disability insurance claim can be a bit different from other types of disability claims. All claimants can benefit from legal advice, even if their claim hasn’t made it to the lawsuit stage quite yet. The earlier you involve an attorney in the matter, the less likely you are to experience delays in the resolution of your case. At Dell & Schaefer, we’ve negotiated disability insurance settlements with Equitable dozens of times and have the experience and expertise needed to guide a disability insurance claim from inception to conclusion. Set up your FREE consultation today to learn more about your legal options.