Biased medical reviews and exams can bring down a deserving disability claim. The above video discusses the process to appeal a disability insurance claim denial. Appeals often mean you must argue against slanted medical reviews by insurance companies and subsequent mishandling or distortion of the evidence.
Independent Medical Exams (IME) and Medical Reviews by Insurance Companies
In most disability claims, an insurer will use an in-house doctor (or nurse) or will hire a third party consultant to review a claimant’s medical records. Sometimes the medical reviewer is not a doctor at all. In most cases, the medical reviewer forms opinions that are in step with the insurance company’s stance.
Frequently insurers will require a claimant to undergo an Independent Medical Exam (IME) to establish whether the claimant’s medical condition is disabling. When used by insurance companies, the IME is often a way to “confirm” the claim administrator’s decision that the insured is not disabled, and thus justifying claim denial.
A few things to keep in mind about medical reviews:
- There are groups of doctors who are regularly sought and used by insurance companies for medical reviews and Independent Medical Examinations; the lion’s share of these doctors’ business is based on IME work.
- The IME doctor is rarely a specialist in the claimant’s medical condition; a general medical doctor or nurse may be examining conditions ranging from a complex spinal cord disorder to kidney disease or chronic fatigue.
- Disabled patients who have been on claim for years may be asked by the insurer to participate in an IME, after which the medical reviewer confirms the claimant is no longer disabled and can now work in a sedentary occupation.
- All it takes is just one IME’s opinion to deny the claimant from receiving desperately needed benefits.
Unreasonable Reliance on Paper Medical File Reviews
Some insurers perform “paper only” medical reviews of the claimant’s records. Rather than arranging an Independent Medical Exam, the insurer conducts a paper review in which there is no personal, “hands on” medical examination of the claimant by a qualified physician. Often, no attempt to contact the treating physicians is made either.
As with the IME, the “reviewing” doctor is employed or contracted by the insurer. The reviewing doctor examines the medical records to reach an assessment on the claimant’s ability to work.
As one might suspect, the opinion of the hired doctor will generally align with that of the insurance company, and support the LTD claim denial. Common scenarios of how paper reviews are used to support claim denial include:
- Ignoring the evidence: By ignoring the evidence presented in the medical files, and regardless that you might already be awarded Social Security Disability benefits — the insurer can simply say the medical records in your claim file do not substantiate “disability” as defined in your policy.
- Cherry picking the evidence: In the medical file review, the claims examiner takes one statement by a treating physician, or one test result, and claims that single piece of evidence supports a denial decision — and ignores other evidence that supports your disability. For example, your physician may write a letter explaining that you are disabled due to a herniated cervical disc and can no longer work. A separate medical file shows that your bloodwork is within normal range, making you appear “healthy.” The insurance company will disregard the fact that you have a significant disability (disc disorder) and try to establish denial based on a selective review of medical evidence (normal blood work).
- Lack of Objective Medical Evidence: After a medical file review, the insurance company argues the claim file does not have any objective evidence of the disability. The reality is, most insurance policies generally do not specifically require “objective medical evidence” as information needed as proof of claim. Still, this denial tactic is frequently used in disability claims across the board. It is a very prevalent denial tactic with in claims for subjective impairments such as depression, anxiety, fibromyalgia or chronic fatigue. These and other disabling conditions cannot be objectively proven in the standard way, and are often based on self-reported symptoms or other evidence. For this reason, lack of “objective medical evidence” such as X-Ray, MRI, surgical records or lab work results, is used as justification to deny benefits.
There is little risk to insurance companies in denying claims.
If your disability insurance coverage is through your employer, your claim is regulated by laws under the Employee Retirement Income Security Act (ERISA). These laws were primarily implemented to protect employee pension benefits in cases of unethical employers.
ERISA law also governs group disability insurance claims. However, in cases of disability insurance denial, these laws favor the insurance company and not the disabled claimant. ERISA rules enable insurance companies to deny claims with ease.
Any strategy used by your insurer to deny a claim must be identified and rebutted on appeal.
This is the landscape for many disabled insureds. Slanted medical reviews are just one cog in a complex wheel of denial tactics. If you have a long term disability claim and have received a letter of denial, you need an experienced team of attorneys that demands justice from insurance companies every day, working for you.
Just because an insurance company denies your disability benefits on the basis of medical file reviews, it does not mean that you are ineligible for LTD benefits. If you are fighting insurance company denial tactics, contact our disability insurance attorneys right away.
We prepare our clients’ claims to handle any insurer’s approach to reviewing medical records. Our law firm will develop your medical files with as much evidence to support your claim as possible, prior to the filing process — or if you have been denied already, during the administrative appeal.
Our long term disability insurance claim denial attorneys present your evidence in a way that clearly shows the impact of your impairment on your day to day life, and on your ability to function in the workplace.
The stronger and clearer your case is, the harder it will be for your insurance provider to deny you. Our LTD denial lawyers understand your medical condition, and have decades of experience specifically litigating these types of claims throughout the United States.
Read our article revealing why independent medical exams aren’t so independent.