Attorneys Gregory Dell and Cesar Gavidia discuss what you need to know about your Illinois Mutual disability income policy and tips to get your claim approved. In this video get a better understanding of what the definition “Disability” is in your policy for claim approval. Learn how Illinois Mutual determines whether a claimant is totally or partially disabled and why not every Illinois Mutual claim denial requires the filing of a lawsuit.

GREGORY DELL: Hi. I’m Attorney Gregory Dell. And today I’m here with Attorney Cesar Gavidia. And we’re going to talk about Illinois Mutual and specifically long-term disability insurance claims and business overhead policy claims at Illinois Mutual. Now, Cesar, we’ve been to the small town of Peoria, Illinois, to the offices of Illinois Mutual. And in terms of the many companies that we deal with, where are they in terms of the size and volume of disability insurance products that they sell?

CESAR GAVIDIA: Well, they’re a smaller company. They probably focus their marketing and their products more to the professional, the medical professionals, chiropractors, doctors, dentists, those types of professions specifically.

You don’t see Illinois Mutual policies too often. But you certainly will have someone with an Illinois Mutual policy contact us with some sort of issue or some sort of problem. And I’ve had two cases involving chiropractors specifically with the way that they were being treated and the way that their claim was being handled specifically with Illinois Mutual.

GREGORY DELL: So with regard to the services we offer with Illinois Mutual so that people know, we help with the application process, which is a unique service we offer. Many law firms don’t do the application process because they’re basically only interested in working on the claim denials.

We help people manage their claims. So even though they get on claim, we help maintain all of the requirements of paperwork, which we’ll get into in a minute. And then, obviously, if the claim has been denied, we have the ability to file a lawsuit against Illinois Mutual and litigate all the way through a jury trial anywhere in the country. So what’s the standard type of definition of disability that you see in the Illinois Mutual policies?

CESAR GAVIDIA: So by default, Illinois Mutual, at least the policies that I’ve encountered, will have an own-occupation definition of disability for a period of time. And then it could change to an any-occupation definition of disability unless you’ve purchased up to a true own-occupation rider that may maintain you in terms of proving your disability from your own occupation through the maximum policy benefit period, which is usually age 65 under Illinois Mutual policies. But it’s a type of policy where you have to kind of buy up to the type of insurance coverage or the level of insurance coverage you need and you want.

GREGORY DELL: So with the Illinois Mutual policies, when you get involved with the application process and the fact that a lot of the policies are sold to independent business owners or medical professionals commonly, what type of information should a person expect to have to present to Illinois Mutual in order to file a claim?

CESAR GAVIDIA: Well, think in terms of an IRS audit because that’s basically– in the words of one client, that’s what it felt like before we got involved. Illinois Mutual wanted all of the company’s financials. They wanted not only the personal tax returns that he and his wife were filing, but the business tax returns as well.

They wanted all of the profit and loss statements from the business. They wanted the general ledgers. They wanted the contributions to pension and retirement plans, basically everything– codes. In this case, it was a doctor– so CPT codes that they were filing, the number of employees that they had. How much were they paying their employees? it’s an extensive and kind of overwhelming request for documentation that they have.

GREGORY DELL: You mentioned CPT codes and financial information. Why does Illinois Mutual want that?

CESAR GAVIDIA: Well, they want to determine, aside from what your occupational duties are and what’s reflected in those codes if you’re a medical professional, the number of procedures you’re performing. If you claim that performing a spinal adjustment is one of your substantial material duties, well, they want to see how many spinal adjustments you’ve done in January, February, and March. They want to see how much you’ve been doing over time.

So it’s not just a request for this year’s CPT codes. It’s years of CPT codes because they’re going to go back and look at what you were doing five years ago, six years ago. Is it the same that you’re doing now? Is it more? Is it less? Did it drop off and then increase? So they’re going to have a lot of questions that they have based on what they see in those codes. But they do that also to see what your level of production is based on your loss of income as well.

GREGORY DELL: And so you just mentioned they might go back five or six years. And someone watching this right away went, oh my gosh. I don’t even know if I have that info. What does that have to do with anything?

And I think the reality is that they’re often looking at what you were doing the last 12 months, give or take. But they want to go back to see, was there a change in the practice at all, more so based upon when you say your medical issues started and what kind of complaints you had. So I think five years may be relevant if they said they’ve been suffering for five years and see how they were working.

And then they’re going to look at a pattern, almost like a bar chart, to see, has there been any change in the number of procedures that you were doing, if you happen to be a medical professional, based upon your complaints? Or did you just get to the point where you just decided, today was the day, and guess what? That wasn’t a day I got hit by a bus or anything. It’s just that was the day I decided to stop. But yet your production stayed the same the whole time.

CESAR GAVIDIA: Right. And I think it gets even, ironically, a little more daunting when you’re going and pursuing a partial disability claim. Because then they are asking for all that information to see what your income and production used to be compared to what it is now because it’s about this formulaic determination of what your monthly benefits should be.

GREGORY DELL: And so you may have a person who has an Illinois Mutual policy. And either their claim’s pending, or they’ve recently been denied. But they’re like, look, I still am doing some work. Or I changed my job. I’m not making as much money. Do they have that option under the Illinois Mutual policy? And how do you guide them through that process?

CESAR GAVIDIA: They certainly could. There’s always that issue or a question of, how much loss do you need before you’re totally disabled? Is seeing one patient a week sufficient for total disability? Is having consistent loss of income or having literally no profits from your business– is that sufficient? Where is that threshold?

And that’s something that we have to come to a decision on and we have to present Illinois Mutual. In many cases, they’ll pay you partial or residual disability without an issue. But that could mean the difference between your benefits stopping at age 65 or going on for lifetime.

GREGORY DELL: If you had a lifetime.

CESAR GAVIDIA: If you have a lifetime rider, right.

GREGORY DELL: In terms of when it gets into dealing with the Illinois Mutual claims people, I find that many of them– it’s a small company. Overall, Illinois Mutual is not a gigantic company. It sounds it like when we say they have a billion dollars in assets. They’re not big. So they’re really, in my opinion, more like a mom-and-pop disability shop versus the monster companies that we deal with.

CESAR GAVIDIA: Right. But they also don’t have a lot of turnover in terms of their employees and their representatives. So a lot of them are very seasoned claim representatives. They’ve been around there for a long time, sometimes decades. So they’re very, very familiar with these insurance policies because it is what they see day in and day out.

They know exactly the documentation they’re going to request, how these particular definitions that appear in these Illinois Mutual policies– how they operate, how they function, what they can even get away with in certain jurisdictions because, remember, these policies are sold all over the country. So how the courts in Florida interpret the definition of disability under an Illinois Mutual policy may be different to how New York interprets it or how California interprets it or Texas. So in being a claim representative that may have been there for 10, 15 years, they’ve seen it all.

GREGORY DELL: And the fact that they can have very experienced claims people can be a disadvantage for some people because sometimes they may do a very thorough claim review and picked up on a few things. And the claimant’s doctor really didn’t do a good job.

And Illinois Mutual, not necessarily having the resources of other companies, uses an outside company. So they look very independent in what they did with a medical review. And they just did a better job than your own doctor did because you weren’t represented. Or you have a doctor who wasn’t really good at documenting the files. And that’s something we can probably clean up once we get involved with the file.

But when you have an experienced claims person who isn’t overwhelmed with so many cases, they have the time to put in to really review the claim. And if there is a questionable inconsistency or a reason to deny a claim, they may be more likely to find that reason and not use the generic nonsense, your symptoms don’t match our findings, or something like that all right. In terms of litigation, what are possible resolutions that someone could expect and the experience of going through a lawsuit if a claim is denied?

CESAR GAVIDIA: I haven’t had to sue Illinois Mutual in a long time, not to say I haven’t had a number of clients with Illinois Mutual issues or claims that I’ve actually successfully resolved. One in particular that comes to mind is a chiropractor that I represented that came to me with a particular issue. I immediately identified what the problem was. I dealt with the Illinois Mutual claim representative. We resolved the problem. And they’ve continued paying them to this day.

It was a specific issue in terms of contract interpretation. And I explained that they couldn’t look at it that way under Florida law. I think they were trying to take advantage, like you were saying, because I think they have more time or resources to put into the claim.

GREGORY DELL: Or they’ve been doing something the same way for so long. And they think that’s the right way. But just because that was their interpretation and you open their eyes to a different interpretation gets into the ambiguity provision, whereas if there is any ambiguity in a disability insurance contract, the ambiguity has to be construed in favor of the insured, which in this case would be the policyholder.

Now, one of the things I think we’ve seen in Illinois Mutual as well with some of their policies is that you may have the opportunity to be disabled from your own occupation but not gainfully employed, which is not a true own-occupation policy because a true own-occupation definition is unable to do duties of your occupation. And then you could go do a different job that has different duties. So that could be a very limiting factor.

CESAR GAVIDIA: Yeah. And one of the issues I’ve seen is someone comes to me. And they say, I’ve been receiving benefits under my Illinois Mutual policy for 10 years. And a friend recently offered me this position in his company where I was going to be serving as a consultant. And then suddenly, I started working. I got my monthly questionnaire from Illinois Mutual. I reported that I was working for this friend of mine.

And suddenly, all these questions started coming up. And they want to know what I was doing, how much I was earning. And I didn’t realize that my policy was going to take into consideration or account the work that I’m doing and the earnings that I’m producing.

GREGORY DELL: I know all of our clients– they don’t do anything without calling us. That way we can always tell them, here’s the implications moving forward. Here’s what you can do. Here’s what you can’t do. And that’s super important because, obviously, you don’t want to jeopardize your benefits on a monthly basis.

So no matter what stage you’re at with your Illinois Mutual claim, if you’re in the process right now or you’re like, I’m thinking of filing, or you’re having issues getting approved or your claim has been denied or your payment’s been delayed, no matter what’s going on, feel free to contact Cesar, myself. Any of our lawyers can help you.

The first thing we’re going to do is ask you to send us a copy of your policy. Send us a status letter, the last letter you got from the company if you’re already involved with them. What we want to do is arrange a set time to have a free initial phone consultation, where we’re going to review whatever information you send us. We’re going to let you know immediately whether or not we think that it’s a situation that we can help you with or the opportunity and chances you have of getting your claim approved or continued, whatever the status may be.

We help claimants all over the country. And the reason for that, Cesar is, as you know, if we have to litigate, we have a couple options in terms of cases. And we’ve litigated right there in the federal court right in Peoria. We can go to the state court there if we have to. We can go to the jurisdiction where the claimant lives. So our office location is never a factor in terms of helping you because of the fact that we have these contacts all over the country.

Very important to you– most people ask, how do we charge? Of course, we never charge any fees or costs unless we make a recovery. The fee is always a percentage of your past and future monthly benefits. And that fee is not set in stone. It changes based upon the amount of your monthly benefit, the risk involved with your claim, the amount of work that we think we’re going to have to put in.

We try to be extremely fair with you to make it affordable for you and also take into consideration the risk that’s involved with moving forward with your case. So I welcome you to call us. And we look forward to the opportunity to speak with you.

If you need assistance with an Illinois Mutual disability insurance claim, contact any of our disability insurance lawyers for a FREE consultation to discuss how we can assist you.