If I had just $1 for all of the articles I’ve written concerning “proof of claim”, claim decision-making, and who makes claims decisions I would indeed be a very wealthy woman by now.
Although in the past I’ve hinted, danced around, and walked on egg shells concerning the reality of claims decisions, here is the hard-hitting truth that treating physicians’ reports do NOT determine disability approval/denial status.
Just last week another insured spent 10 minutes telling me how disabled he is and that his insurance company could never NOT pay his claim. “Here we go again”, I thought to myself, and after my 10 minute response I couldn’t help think the insured didn’t believe a word I said.
One of the first things, Tim Arnold, Unum’s Chattanooga claims VP announced was that “claims decisions would no longer be made using proof of claim provided by treating physicians. All claims decisions would henceforth be made only as a result of INTERNAL medical reviews, including IMEs”.
Harold Chandler and the good ol’ boys from Provident and Paul Revere took claims decisions way outside the normal previous practice of using “a consensus of medical opinion” to “only OUR opinion counts.” This is one of the reasons why UnumProvident was forced to reassess 250,000+ claims in 2000, using, let’s say, a more objective review process.
Although all disability insurers spend a great deal of time and effort chasing patient records the presumption has always been made by insureds that “medical records are believed by insurers and taken as credible verification for disability approval.” Nothing could be further from the truth! Those insureds who are still believing that “because the doc says so” claims have to be approved”, are managing claims punting into the wind.
The truth is, disability insurance companies obtain patient notes to support worst case medical impairments while at the same time dismissing credible treating physician restrictions and limitations as “advocating for insureds” by over restricting patient’s inability to work. Of course, it is always much easier for insurance companies when the only medical opinions considered are their own!
The hard-hitting truth here is that no insurance company is compelled or required to “take the physician’s word about anything.” In one of my articles I informed my readers that the “Treating Physician’s Opinion” rule was thrown out by Social Security and subsequently by the courts a long time ago.
The “Treating Physician’s Rule” required agencies, including insurance companies, to give deference to medical opinions rendered by treating physicians. Of course, this didn’t last long as judges were influenced by the insurance lobby.
The closest thing we have to the “Physician’s Rule” is Unum’s RSA amendment requiring standard disclosures when Unum disagrees with treating physicians, although Unum basically ignores the RSA amendments anyway. The RSA also does not apply to other insurers who basically rely on their own cheaply obtained insurance industry opinions.
So why do so many insureds still think that insurance companies are compelled, required, mandated, have to, or made to consider patient records and reports when making liability determinations?
In my opinion, insureds by far, still do not have a clue as to what disability products are, and how the process works. Claimants can throw out Employer Group claims subject to ERISA on this issue due to state and federally granted “discretionary authority” that gives insurers complete discretion to decide who gets paid and who doesn’t.
To be clear. No insurance company is required to consider the opinions of treating physicians before they decide to pay or not pay claims. It doesn’t matter what your physician’s report. If the internal medical reviews or IME reports are not favorable to insureds, claims are denied leaving it up to insureds and their attorneys to prove legitimate disability on appeal, or in a court of law.
Having said all of the above, I admit there is a point (thank goodness) when insurers begin to look like criminal robber barons if they don’t pay certain claims. This is why I spend so much time writing about what “credible medical proof of claim” should look like. (According to my blog statistics, articles concerning medical reporting aren’t read or considered popular, although they should be.)
The reality of disability claims is that claim decisions are not made based on what your doctors say, but on what your insurers can obtain as proof showing insureds are not disabled and can return to work. Insureds who still believe insurers MUST pay claims because treating physicians say so, unfortunately do not understand the reality of disability claims.
Disability claims, in my opinion, are paid at an overall rate of less than 50%. By the time we remove ERISA claims denied at 24 month change in definition, 24 month mental and nervous periods, and unfair claims adjudication, I think the percentage might be a great deal lower, more like 35%.
Every thing that happens, or is decided by an insurance company is how “things are positioned.” The reality of the claims process is that insurance companies have no mandate to consider the opinions of treating physicians and no insurer MUST approve benefits based on what your physicians report.