Disability Claims Solutions

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Occasionally for the disabled, it often feels as though one has every known impairment in the ICD-10 medical billing book. Head hurts, back hurts, gastritis, arthritis, joint pain, Lyme disease, FMS, CFS, POTS, IBS, HIV, DDD, DJD, and on and on. And, while impairments can add up sometimes into co-morbidities, it’s very important to “manage and position” disability claims with diagnoses that are diagnosed, documented, and when possible, proved.

To begin, insurance companies always use risk and statistical probability to sort things into nicely arranged boxes. For example, the risk of someone having more than one insured reimbursable fire in a home in their lifetime is 10,000,000:1+/-. Therefore, anyone who has several fires in their home could be presumed to be a firebug.

Likewise, insureds who submit disability claims with lists of many diagnoses could be presumed to be in the category of somaticized, or hypochondria since the probabilities of having two or more combined diagnoses are so high.

What do you suppose is the probability of someone having Lyme disease, POTS, and IBS at the same time? It’s probably close to at least 2,000,000:1. If you add CAD to this list the odds are increased to around 50,000,000:1.

What I am getting at here is that insurance reps and managers reviewing claims containing an entire page of diagnoses will react in accordance to how they have been indoctrinated and trained. One Unum claims manager reviewed one of my files containing a list of at least 20 separate diagnoses and said, “If this person actually had all these things they should either be dead or in intensive care!”

Another manager reviewed a claim for chemical and environmental sensitivity and said, “Let’s do this. Let’s tie her to a tree for a week. If she’s still sick, we’ll pay the claim.”

When filing a disability claim, it is very important for insureds to distinguish between what they THINK they have, and what has been officially diagnosed and documented by treating physicians. Sometimes symptoms need to be separated from official diagnoses with objective evidence in order to shorten the co-morbidity of the claim.

Of course I’m taking a slight negative risk here because there are insureds who will fight to the death supporting diagnoses they are sure they have, diagnosed or not. But, the truth is only official diagnoses documented by physicians should be reported to insurers. Specifically, high negative probability of certain co-morbidities should be eliminated IF they have not been backed up with objective evidence and an official diagnoses.

I realize that disability claims DO NOT require “objective evidence” in order to be paid, but where available objective tests validate claims of disability, particularly if the list of co-morbidities is a page long.

Insureds need to be careful not to “over do it” by claiming multiple co-morbidities that make it appear one should be so sick to be near death or in intensive care. In other words, there is a point of alleging so many medical impairments that in combination cause insurers to disbelieve all of them!

Multiple, long-lists of impairments DO NOT insure successful claims. The truth is, when the impairment list becomes long and improbable, insurers will reject the entire list and send you back to work. The mathematical probabilities of having so many co-morbidities at once is just too high!