Insurance companies base claims on generalities, meaning, if statistically 85 per cent of people recover in two to four weeks, you should too. But, what happens if you are one of the 15 per cent that do not recover in this time period?

Without ever meeting you in person, your claim is decided upon by an adjuster.
The verdict is based predominantly from reports and doctor’s notes and his or her interpretation of this information and your situation.

Conversely, when doctors determine the severity of a situation, they do so based on seeing the patient and considering the effects of a disability. Doctors look at the side effects felt on a day-to-day basis, and take into account health history.

In short: You are case specific to your doctor, whereas your case is generalized to your adjuster.

The adjuster also has no prior knowledge of your workplace. There is little understanding of your individual experience and training or any other psychological or physical limitations. The adjuster must work with what is common to your line of work and those with that job.

Fate is left with an adjuster with no specific medical, workplace or vocational training. The result? The good likelihood that an erroneous decision will be made as claims can easily be denied based on generalities when specific needs are not taken into account.

One of my first cases was an example of a wrongful claim adjustment during the transitional period from short-term to long-term disability. My client received notice that her two years of benefits was about to end. From her file, the claims adjuster knew she was a high school graduate who worked as a laborer for the city.
The adjuster’s suggestion was that my client should be a telephone operator. However, what the adjuster failed to notice was that she was deaf! We made sure she got her benefits after that.

You may be thinking how often can an adjuster really be wrong? In the 23 years I’ve been working, every time I’ve taken on a client the adjuster has been wrong.

If your claim has been denied and you think this cannot be reasonable, get a legal opinion. Trust your gut, in my experience; you are likely to be right.