All insurance companies pinpoint criteria in claims they feel is “suspicious”. Therefore, I thought it a good idea to be clear about situations that cause insurers to off the deep end.Authori
Alteration and/or white out appears on the claim form physician’s statement, and/or other supporting document. (The insurance company will send the claim forms back to the originator and ask if the alternation is legitimate. You should ask your physician or others to initial any changes, white outs, or line through before sending to the insurance company.)
Authorization signatures and/or dates are absent from pertinent documents. (Disability insurers will assume you have a “problem with” signing certain documents. Something to hide? They will send back the document and ask you to sign it. Some companies threaten to suspend benefits until signed. This action is out of contract, but it can deprive you of income in the meantime.)
Medical terminology on the document is misspelled or misused. Or, medical terminology is missing. (Assumption that your medical providers are not qualified. Investigations will be made to “check out” your medical providers.)
The severity or length of disability is inconsistent with the illness or injury. (Insurance company believes you are malingering or “faking” disability for secondary gain. They will write or call your physicians in an attempt to persuade him/her to their point of view—namely that you can work beyond a certain recovery period. Internal medical reviews then follow stating your physician “over restricted you.”)
An excessive number of documents or unsolicited documents are submitted. (Looks like you have at least sedentary work capacity. If you are in the any occupation period, downloading documents from the internet en masse may show you have the ability to work at another occupation. If your insurer doesn’t find your physician credible, downloaded information from the Internet won’t be taken seriously either.)
Reports, receipts, invoices or records are on plain stationery rather than on professional letterhead. (This refers to doctor’s reports and other documents from professionals which normally should be printed on letterhead. The insurance company will contact, and/or investigate the author to ensure their credibility.)
Incorrect information appears on the documents. (Disability insurers are always checking for “consistency” of reported information. If something is different or out of place, the claims specialist will make calls and investigate why the information is different than what was previously reported.)
Medical reports are incomplete or appear to be altered. (Altered medical reports can be very serious—fraud. Any documents which have been changed or altered will be investigated. If true, you may be reported to your state’s attorney general who could prosecute the offender for fraud. Most common mistake is for insureds to mark on, add, or change information on patient notes.)
Medical records are submitted directly by the claimant. (While all ERISA Plans state very clearly that medical “proof of claim” should be submitted by claimants, insurers really do not like it when the “chain of evidence is broken. However, it is better for claimants to submit their own patient notes than to have an insurer allege they never get them.)
The claimants changes attending physicians frequently. ( Insureds are permitted to change physicians and there is no reason to suspect insureds for doing so. However, some claims seem to indicated insureds are “doctor shopping” trying to find physicians who will support what they claim is wrong with them. In this instance, insurers will investigate frequent changes of physician.)
The attending physician is not in the same geographic region as the claimant. (Insurance company assumes the insured is not in “regular and on-going treatment”, a stipulation in the definition of disability in most policies. Or, assumption you are staying with a physician who is advocating for you and your claim.)
The attending physician’s specialty is not consistent with the diagnosis. (This should really never happen. Your primary care physician should always be qualified in the specialty you need. The insurance company will not accept the medical information from a doctor who is not qualified to treat your impairment. Your claim may be closed. For example, if you have fibromyalgia, your physician should be a Rheumatologist. A family practice physician isn’t the best specialty for cardiac problems etc. No weight will be given to this type of medical information.)
The claimant is never or rarely at home to receive telephone calls, or cannot be disturbed when called. (Disability Company assumes you are working or are active during the day. Claims specialist will begin calling you at home at various times of the day to see if you are working and not telling them. In this day and age of turning cell phones off, or not answering, DCS recommends all communications in writing only.)
The claimant is very demanding and requests payment of benefits with multiple phone calls. (Disability Company assumes the claimant is over reacting because they really aren’t impaired. Nothing is usually done, per se, by the company, but it certainly makes for a miserable communication while managing the claim.)
The claimant is uncooperative and refuses to provide tax returns or sign authorizations for release of information. (If claimants do not provide signed authorizations etc. they may be prejudicing the insurance company’s ability to investigate the facts, and claims may be denied. The claim will be referred to the legal department and the claimant receives a warning.)
The claimant has a history of frequent disability claims. (Insurance company assumes the claimant is consistently attempting to malinger and receive benefits without really being impaired. Surveillance and other risk management activities will take place.)
The claimant’s illness or injury occurs shortly before a layoff, strike, termination, or downsizing. (Insurance company assumes you went out on disability to get an income before your job was downsized. The claim specialist will call and document information from your employer. Your claim may be denied. “Some money is better than no money.”)
The claimant’s illness or injury occurs immediately following disciplinary action, demotion, or being passed over for a promotion. (Same as above.)
The claimant’s lifestyle does not coincide with his/her reported known income. (Company assumes you are hiding resources or income. Fraud unit will investigate the source of your income and they will request copies of your income tax returns. A FICA check might be made as well.)
The claimant works for a family member. (Insurance company assumes you will not report the full amount of earnings you are actually receiving. Also, the full amount of hours worked will not be reported accurately. Surveillance and payroll records are requested before any checks are released. The presumption here is that all money is paid to the non-disabled spouse.)
The claimant’s trade or occupation lends itself to easy opportunities for self-employment. (This brings into question whether you are in fact doing the material and substantial duties of your own or another occupation. Any self-employment will be scrutinized to make sure you aren’t really doing your occupation under cover of self-employment.)
Unexpected or unexplained noises are heard in the background when speaking to the claimant. (Assumption is that you are either engaged in self-employment, or are watching grandchildren etc. The claims specialist will request a field visit to “check it out.”)
The claimant’s injury or diagnosis is inconsistent with the medical treatment he/she is receiving. (Your psychologist fills out your forms saying you are severely depressed, but only sees you every 6 weeks. This isn’t appropriate treatment. Your claim could be denied, or the insurance company will contact all treatment providers and find out why they aren’t seeing you more often.)
The claimant protests suggestions that he/she is able to return to work and never seems to improve. (Assumption of malingering. A doc to doc call will be made to all treatment providers and attempts will be made to find out why the medical treatment plans aren’t working.)
The claimant refuses an IME or cancels or fails to keep appointments for an IME. (Requirements for IME’s are now contractual in most cases. Failure to submit to an IME is cause for denial of a claim. You will receive a letter telling you that. Refusing to cooperate with an IME request may also suggest you are malingering.)
Treatment dates appear on holidays or other days that medical facilities would not normally see patients. (Assumption of fraud, or treating with inappropriate or alternative medicine physicians. Claims specialist will investigate and find out why this is happening.)
The claimant hires an attorney or mentions hiring an attorney very early in the claim. (This is very commonplace now; insurance companies generally won’t pay too much attention to this. Once there is an attorney of record, the claims handlers can only communicate with the attorney. This does not apply to consultants.)
The claimant later develops additional injuries allegedly related to the initial injury or illness when it appears the claim will be terminated. (Assumes you may be injuring yourself in order to stay on claim rather than going back to work. Calls will be made to all physicians, and they will be asked to explain the frequent illness or injuries.)
The claimant is over familiar with insurance terminology and the handling of disability claims. (Assumes the claimant has familiarized themselves just enough to “get over on” the insurance company. Assumes claimant knows how to “circumvent the system.” The claims handler will be on the look out for attempts from the claimant or a spouse to manipulate, or control the claim review process.)
The address where the claimant is receiving checks is somewhere other than his/her physical residence. (The address may be a P.O. Box, a mail-drop, or a relative’s address. The claimant does not want to be found or surveiled. The claims handler will refer the claim to a field investigator and the address and location of the claimant will be identified.)
Co-workers and/or other sources, including anonymous callers, report that the claimant is not disabled and/or is working, or report claimant activity that is inconsistent with the disability. (Interestingly, these reports generally come from the claimant’s employer or ex-spouse who calls and tells the claims handler there are peers and other employees who’ve seen the claimant about town. Generally, the claimant will be surveiled.)
The claim is filed shortly after coverage becomes effective. (Indication the insured has a preexisting condition. Generally, any claim filed within a year of the policy becoming effective would be subject to pre-existing condition provisions in the policy as well as investigation.)
There is a long delay in the submission of the claim from the date of injury or illness. (This assumes the claimant stopped working for reasons other than disability. In this case the medical information is investigated very carefully to make sure the claimant was under medical treatment and consultation the entire period the filing was delayed.)
The claimant’s family members know nothing about the claim. (Assumption of malingering. If the claimant is really impaired, family members generally will know about it. Sometimes family members and neighbors can be contacted.)
The claimant was experiencing financial difficulties and/or domestic problems prior to the submission of the claim. (Assumes submission of disability claim for secondary gain. The circumstances before, during and after a claim is submitted is investigated.)
Every year it seems as though insurers are adding more “red flags” to their claims procedures. This is why it takes a full 24 months for claims handlers to learn how to “cheat review” claims.
Nevertheless, “red flags” ARE internally communicated to claims handlers and they are performnce managed as to how well they investigate them. The good news is, that those in the know who are aware of the “red flags” also know how to manage them, and resolve any problems.
