Individual Disability: Choose Your Policy Wisely
A few years ago, one of our clients,* a dentist with his own practice, came to us after his insurance company denied his disability claim. The insurance company informed him that, under the terms of his individual disability policy, he was not covered.
Background . . .
Our client was injured in an automobile accident. His car was totaled, but fortunately he survived. He had no sight or hearing loss; he had no internal damage, no vital organs were affected; and he did not sustain any amputations. However, due to the severity of the impact, he did sustain permanent damage to his left arm, making it impossible for him to work on patients.
To our client, it seemed like a clear-cut case of disability. So, he went ahead – on his own – and filed a claim. He felt secure in the knowledge that he had purchased his own private disability policy when he first opened his practice – a policy, he thought, would protect him and his business should he ever need it; a policy for which he had paid costly premiums for over two decades. Like many other business owners and professionals we consult with, our client was mistaken.
Because he was not completely incapacitated, our client was able to keep his practice going by managing the business, consulting with patients, and leaving the hands-on care of his patients to his partner and an associate. According to the insurance company and our client’s individual disability policy, however, in order to receive disability benefits he was not permitted to work in any capacity – period. Because our client returned to work, even though he no longer worked as a practicing dentist on patients, he forfeited his disability benefits.
Having A Disability Policy Is Not Enough . . .
What our client did not realize is that purchasing an expensive disability insurance policy with high monthly benefits was not enough to secure his financial future. He clearly did not read his individual disability policy carefully enough before making the commitment. Unfortunately, he later learned that is also is critical to purchase the right policy – one, for example, that would pay him benefits while he continued to work in his practice in a different capacity.
The attorneys at DeHaan Busse can help you to avoid the same mistake. We often consult with clients before they purchase an individual disability policy to make certain that not only do they have enough coverage, but also the specific coverage they need. If you need assistance in reviewing an individual disability policy, contact us at 631-582-1200.
*Details about the client have been altered to preserve client confidentiality.
VA Makes Things Easier For Veterans With PTSD
On July 12, 2010, Eric K. Shinseki, Secretary of Veterans’ Affairs, announced the publication of a final regulation in the Federal Register pertaining to veterans suffering from post-traumatic stress disorder (PTSD). The intention is to facilitate the process for veterans with PTSD claims who are seeking health care and disability compensation.
Says Secretary Shinseki, “This nation has a solemn obligation to the men and women who have honorably served this country and suffer from the often devastating emotional wounds of war. This final regulation goes a long way to ensure that Veterans receive the benefits and services they need.”
Essentially, veterans who have suffered PTSD in a war zone no longer will have to corroborate a stressor related to fear of hostile military or terrorists so long as a VA physician determines that the veteran’s stressful experience supports a diagnosis of PTSD. In addition, the new rule will ease the claims process for non-combat veterans in a war zone who may have experienced a stressor related to hostile military activity.
Currently, over 400,000 veterans receive disability compensation for service-connected PTSD. The VA’s goal is to make sure veterans get the benefits they need with fewer delays. The new rule on PTSD combined with the streamlined claims form are a step in the right direction.
New Regulations On PTSD Claims – Questions And Answers (Source: www.va.gov)
What is Post-Traumatic Stress Disorder (PTSD)? Post-Traumatic Stress Disorder (PTSD) is a condition resulting from exposure to direct or indirect threat of death, serious injury or physical threat. The events that can cause PTSD are called “stressors” and may include natural disasters, accidents, or deliberate man-made events/disasters, including war. Symptoms of PTSD can include recurrent thoughts of a traumatic event, reduced involvement in work or outside interests, emotional numbing, hyper-alertness, anxiety and irritability. The disorder can be more severe and longer lasting when the stress is human initiated action (example: war, rape, terrorism).
What does this final regulation do? This final regulation liberalizes the evidentiary standard for Veterans claiming service connection for PTSD. Under current regulations governing PTSD claims, unless the Veteran is a combat Veteran, VA adjudicators are typically required to undertake extensive record development to corroborate whether a Veteran actually experienced the claimed in-service stressor. This final rulemaking will simplify and improve the PTSD claims adjudication process by eliminating this time-consuming requirement where the claimed stressor is related to “fear of hostile military or terrorist activity,” is consistent with the places, types and circumstances of their service, and a VA psychiatrist or psychologist, or contract psychiatrist or psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD.
What types of claims for VA benefits does the final regulation affect? The final regulation will benefit Veterans regardless of period of service. It applies to claims for PTSD service connection filed on or after the final regulation’s effective date, and to those claims that are considered on the merits at a VA Regional Office or the Board of Veterans’ Appeals on or after the effective date of the rule.
Why is this final regulation necessary? The final regulation is necessary to make VA’s adjudication of PTSD claims both more timely and consistent with the current medical science.
How does this final regulation help Veterans? The final regulation will simplify and streamline the processing of PTSD claims, which will result in Veterans receiving more timely decisions. A Veterans will be able to establish the occurrence of an in-service stressor through his or her own testimony, provided that 1)the Veteran is diagnosed with PTSD; 2)a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted confirms that the claimed stressor is adequate to support a PTSD diagnosis; 3)the Veteran’s symptoms are related to the claimed stressor; and 4)the claimed stressor is consistent with the places, types and circumstances of the Veteran’s service and the record provides no clear and convincing evidence to the contrary. This will eliminate the requirement for VA to search for records, to verify stressor accounts, which is often a very involved and protracted process. As a result, the time required to adjudicate a PTSD compensation claim in accordance with the law will be significantly reduced.
How does VA plan to monitor the need for examiners in various regions of the country and how does VA plan to respond if it is determined that more examiners are needed in a particular region? The Veterans Health Administration (VHA) has written in to the FY11-13 Operating Plan the need for additional staff to support doing adequate, timely exams. VHA proposes: the need for additional staff to support doing adequate, timely exams. VHA proposes: “A8. Increase mental health field staff to address the increase in C&P examinations and develop monitoring system to ensure clinical delivery of mental health services does not decrease in VHA.” Specifically, VHA has requested 125 clinicians for FY11 with additional 63 staff in FY12 if the need exists. If the Operating Plan and the proposed budget are approved, VA proposes asking the Veterans Integrated Service Networks (VISNs) to develop plans for distributing the funds in order to ensure adequate coverage at sites based on the number of claims being processed; the VISNs are well positioned to determine these regional needs.
How does the regulatory revision affect PTSD service connection claims where an in-service diagnosis has been rendered? The new regulation does not apply to the adjudication of cases where PTSD has been initially diagnosed in service. Rather, under another VA rule, 38 CFR Section 3.304(f)(1), if a Veteran is diagnosed with post-traumatic stress disorder during service and the claimed stressor is related to that service, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran’s service, the Veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor.
Is the new regulation applicable only if the Veteran’s statements relate to combat or POW service? No. The rules state that the stressor must be related to a “fear and hostile military or terrorist activity,” and the claimed stressor must be “consistent with the places, types and circumstances of the veteran’s service.”
What circumstances will still require stressor verification through DoD’s Joint Services Records Research Center (JSRRC), VBA’s Compensation & Pension Service (C&P Service) or other entity if a Veteran claims that his or her stressor is related to a fear of hostile or terrorist activity? The regulatory revision will greatly lessen the need for undertaking development to verify Veteran’s accounts of in-service stressors. Now, stressor development may only need to be conducted if a review of the available record, such as the Veteran’s service personnel and/or treatment records, is inadequate to determine that the claimed stressor is “consistent with the places, types and circumstances of the veteran’s service.” In such circumstances, the Veteran’s Service Representative (VSR) will determine on a case-by-case basis what development should be undertaken.
However, it is anticipated that in the overwhelming majority of cases adjudicated under the new version of Section 3.304(f), a simple review of the Veteran’s service treatment and/or personnel records will be sufficient to determine if the claimed stressor is consistent with the places, types and circumstances of the Veteran’s service. We also believe that, in some cases, a Veteran’s separation document, DD-Form 214, alone may enable an adjudicator to make such a determination.
As the regulatory revision seems to require an enhanced role for the examining VA mental health professional, whose role is it to determine whether the claimed stressor is consistent with the Veteran’s service? VA adjudicators, not the examining psychiatrist or psyhcologist, will decide whether the claimed stressor is consistent with the Veteran’s service.
Is a Veteran’s testimony about “fear of hostile military or terrorist activity” alone sufficient to establish a stressor? Yes, if the other requirements of the regulation are satisfied, i.e., a VA psychiatrist or psychologist confirms that the claimed stressor is adequate to support a PTSD diagnosis and that the Veteran’s symptoms are related to the claimed stressor, and the stressor is consistent with the “places, types and circumstances of the Veteran’s service.”
Are the stressors accepted as adequate for establishing service connection under new Section 3.304(f)(3) limited to those specifically identified in the new regulation? No. The examples, given in the revised regulation do not represent an exclusive list in view of the use of the modifying phrase “such as” that precedes the listed examples. Any event or circumstance that involves actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, would qualify as a stressor under new Section 3.304(f)(3).
How will the Veterans Health Administration (VHA) work with Veterans Benefits Administration (VBA) on the new regulation? VHA was actively involved in discussion with VBA of the new regulation and fully supports the new regulation.
The new regulation will provide fair evaluation for Veterans whose military records have been damaged or destroyed, or for whom no definitive reports of combat action appeared in their military records, even though they can report such actions and it is reasonable to believe that these occurred, given the time and place of service.
This will be especially beneficial to women Veterans whose records do not specify that they had combat assignments, even though their roles in the military placed them at risk of hostile military or terrorist activity.
This means that more Veterans will become eligible for VA care and thus be able to receive VA care for mental illness related to their military service, as well as receiving full holistic health care. VHA will work actively with VBA on implementing the regulation. VHA staff’s main role is as clinicians conducting C&P interviews to establish diagnoses and obtain other information to be used by VBA raters to determine the outcome of claims.
The new regulation will not change the diagnostic elements of the C&P interview, but may change what additional data are collected for use by VBA raters.
Legislative News
Source: www.ins.state.ny.us (James J. Wrynn, Superintendent of Insurance, NY)
Consumers Should Evaluate Their Life Insurance Options
Did you know that New York consumers have a minimum 10-day free look period after buying a life insurance policy?
“It’s always best to shop for insurance and to understand all the details of a policy before buying it. However, an important consumer protection is the right of the policyholder to return the policy during the free look period. The free look period allows a consumer to cancel a life insurance policy without penalty within a set timeframe if the consumer reconsiders a decision to buy a policy,” Insurance Superintendent James Wrynn said.
New York law requires insurance companies to give consumers a minimum free look period of 10 days and a maximum of 30 days, depending on the policy. A 30-day free look period is required for any policy through the mail and a 60-day period is required if another policy is being replaced. The free look period for each individual policy is shown on the policy’s face page.
“Buying a life insurance policy is an important decision because adequate insurance helps safeguard a family’s security when the policyholder passes away. The need for life insurance can vary with a consumer’s age and responsibilities. Consumers should review their life insurance needs every few years to keep up with changing financial and personal circumstances,” said Wrynn.
The New York State Insurance Department urges consumers to carefully analyze their need for life insurance, understand how the cost of life insurance is determined and evaluate the different types of insurance before deciding to buy a policy.
Paying off a mortgage, providing for children’s education or ensuring a spouse has an adequate monthly income are just a few of the reasons people purchase life insurance. The premium rate for a life insurance policy is largely based on a sharing of the risk of death by a large group of policyholders and interest earnings on the invested portion of the premium by the insurance company.
For the most part, there are two types of insurance plans – term or permanent life insurance, or some combination of the two. Term insurance provides protection for a specified period of time. Permanent insurance – sometimes called cash value life insurance because it may generate a savings element – is designed to provide coverage throughout a person’s lifetime.