Which questions are ambiguous, how to describe your work, and why the benefit application determines success or rejection.
The disability insurance claim application is crucial in determining whether your claim is successful or rejected. The often lengthy questionnaire forms the basis on which the insurer assesses your case and looks for potential issues. The greatest risks lie in an inaccurate description of your work and in statements that give the insurer cause to subsequently review your initial health information. Rogert & Ulbrich will guide you through the application process and secure your claim from the outset.
Why the benefit application determines success or rejection
When you apply for benefits from your disability insurance, the insurer will send you a comprehensive questionnaire. It asks about your illness, your occupation, your daily routine, and your treating physicians. This application is not a mere formality, but rather the crucial basis for the benefits assessment.
From his previous work on the insurance company side, lawyer Dario Kovac knows exactly how such an application is evaluated. The insurer systematically checks it for inconsistencies, inaccurate job descriptions, and indications that warrant a renewed examination of the information provided during the contract signing process. Every statement is later compared to your medical reports and other explanations.
The first answer is difficult to correct. Therefore, you should prepare the questionnaire carefully and not fill it out under time pressure.
Before you submit the questionnaire: Have it checked, because later corrections are difficult to implement.
Recognize and precisely answer ambiguous questions
Many questions in the benefits application are vaguely or imprecisely worded. An imprecise answer can unintentionally cause problems. These principles will help:
- Answer only the questions asked.Answer the question precisely and only within the specified time period. Additional, unsolicited information creates unnecessary grounds for attack.
- Don't guessIf you are unsure about a date or diagnosis, honest uncertainty is better than a false, seemingly precise statement.
- Maintain consistencyYour information must match what your doctors report. The insurer will exploit any discrepancies between your application and your doctors' reports.
- Neither downplay nor dramatizeDescribe your limitations objectively and realistically. Exaggerations as well as understatements weaken your position.
If in doubt, it is worthwhile to have a question legally classified before answering it, instead of filling it out on a whim.
Is a question unclear to you? Have it clarified before you answer – the wording of your answer may be crucial later.
Describe your professional activity correctly
The most important and most frequently evaluated part of the application is the description of your professional activity. This determines whether the insurer recognizes your degree of occupational disability and whether they can refer you to another profession.
Therefore, describe your most recent job as specifically as possible, exactly as it was when you were healthy. Important details include the individual tasks, the time commitment, the physical and mental demands, and your responsibilities. A general job title is not sufficient.
A vague description gives the insurer leeway to portray individual activities as still reasonable or to construct a supposedly comparable profession. We explain how this referral works in detail and where its limits lie in a separate article.
Are you unsure how detailed your job description should be? Have it reviewed before using it as the basis for the insurer's assessment.
Health information in the event of a claim: Cooperation instead of a new reporting obligation
Here, a distinction is important that is often confused. The pre-contractual duty of disclosure is part of the contract formation process: At that time, you had to answer the insurer's health questions truthfully. No new duty of disclosure arises when a claim is made. What now applies to you are duties to cooperate and provide information, meaning the obligation to describe the insured event truthfully and to assist in the investigation.
Nevertheless, the claim process is often precisely the moment when the insurer retrospectively reviews your original health information. They compare the information you provided in the application with the requested documents to ensure that everything was correctly stated when the contract was concluded. Therefore, the information you provide when making a claim should be consistent with your medical history.
Whether a deviation actually has consequences depends on the rules regarding pre-contractual disclosure obligations, which we explain in a separate article. Regarding the benefit claim: Do not conceal anything, but also do not draw hasty conclusions about previous diagnoses whose significance you do not fully understand.
Are you worried that previous diagnoses could cause problems? Have this clarified before submitting your application, instead of leaving it to chance.
Release from confidentiality obligations and data disclosure – how far do you have to go?
To verify your information, the insurer regularly requests a release from confidentiality for doctors, hospitals, other insurers, and authorities. You are required to cooperate in the investigation. However, you are not obligated to sign a blanket, unlimited power of attorney without having it reviewed.
In many cases, you can insist on specific release of information: The insurer informs you which details they wish to request, and you decide on a case-by-case basis or submit the documents yourself. This allows you to retain control over sensitive health data and prevents the insurer from indiscriminately researching your entire medical history.
The right balance is crucial: those who refuse all cooperation risk the insurer being released from its obligation to pay benefits. A moderate, controlled approach, on the other hand, is permissible and advisable.
Has your insurer presented you with a comprehensive release from confidentiality obligations? Have it checked whether a release specific to a particular event is sufficient before you sign.
Checklist: How to fill out the disability insurance claim form
This checklist will help you keep track of the most important points:
- Take your timeDo not fill out the application under pressure. A thoughtful response is more valuable than a quick one.
- Collect documentsPlease have medical reports, diagnoses, your insurance contract including terms and conditions, and a copy of your original application ready.
- Describe the activity precisely: Record the tasks, time allocation, and physical and mental demands of your most recent job.
- Answer questions preciselyAnswer only to the extent and within the timeframe requested and avoid making assumptions.
- Check consistency: Compare your information with your medical history to avoid any contradictions.
- Check for release from confidentiality obligationsDo not sign any unlimited general release without review.
- Have it checked before sendingA legal review will uncover weaknesses while they can still be rectified.
This article is part of our overview of the five most common reasons for rejection in disability insurance. We will explain the pre-contractual duty of disclosure and the referral to other employment in detail in separate articles. You can find an overview of our work on our insurance law page.
Do not submit the application without having it reviewed. Have it checked beforehand, while the wording can still be adjusted.
Rogert & Ulbrich – Your lawyers in insurance law
Rogert & Ulbrich assist policyholders nationwide with claims for benefits under their disability insurance. Attorney Dario Kovac, who is familiar with insurers' review and rejection strategies from his previous work on the insurers' side, serves as the contact person for insurance law. We combine this insider knowledge with the firm's consumer protection experience gained from major cases in banking, capital markets, and automotive law. This allows us to engage with insurers on equal footing.
We prepare your claim, draft the job description with you, review the required declarations and the confidentiality waiver, and ensure that your information is consistent and reliable. If the insurer still rejects your claim, we will pursue your claims out of court and, if necessary, in court. We will involve any existing legal expenses insurance early on and obtain the coverage confirmation for you.
Are you about to apply for your disability pension, or has your insurer already rejected your application? Get in touch and secure your rights.
