One of the most important criteria used by insurance companies to deny claims, or I’m sure they would say, “evaluate claims”, is to apply the Objective Evidence Standard even when very few actual insurance policies/Plans require the Objective Evidence Standard as Proof of Claim. This issue is probably the most misunderstood criteria involving disability claims, and the industry knows it.
For as long as I can remember Unum, and other insurance companies have been exploiting the concept of “objective evidence” as well as asking judges and juries to decide what vague policy and Plan language means.
There have probably been thousands of litigations won and lost for the same issue over the last 50 years, and still medical proof of claim is still used to deny claims based on allegations of “no objective evidence to support R&Ls”. Again, I’ve coined my own definitions for objective and subjective evidence.” See below for my own definitions based on my experience.
Objective evidence is “any medical diagnostic means, such as lab tests, radiographic films, etc. used to identify and specifically locate the source of disease, which can then be used by qualified physicians to accurately diagnose and treat their patients.”
Subjective evidence identifies disease by evaluative evidence of consultative observation, longstanding patient history, symptom reports, and clinical examination sufficient to identify and treat chronic disease.
Patient “self-report” means using symptom information reported by patients in combination with the above to identify and treat disease for which there are no “diagnostic tests” that can be used to objectively prove the patient has what the physician says they have. Clinical diagnoses are based solely on the patient’s history and the expertise and skill of the treating physician to connect the patient’s symptoms with specific diagnoses.
Sounds pretty technical doesn’t it? All of the insurance companies at one time or another have alleged “no objective evidence” even when the objective evidence standard is not required in the policy. It isn’t required in the policy because not all impairing conditions have objective evidence that can be used, diagnostically, to prove patients have what they say they have. It is an open loophole past and present for insurance companies to pull the plug on nothing more than a biased opinion.
Although some companies such as Lincoln and The Hartford have added “objective evidence” to their policy language, it has a hard time holding up in court if the Plan or policy doesn’t specifically require it. Largely, this is an attempt to limit payment on claims involving connective tissue disease such as FMS, CFS, back problems citing pain etc.
Whatever steps insurers take to allege “no objective evidence”, they often forget to inform their own IME physicians not to use the old lingo in their reports. When they do, it’s a dead give away that they are familiar with the agenda to deny claims and are buying into it.Although “the jig was up” about 10 years ago, insurance companies still use the same old “objective evidence standard” arguments to deny claims.
When insureds have a disabling impairment that is subjective, great care must be exercised to medically support claims in ways that focus/point to clinical history, and treating physician evaluation based on examination. There should be mentions that the patient was physically examined at every visit. There are other ways of supporting subjective claims, and if you have a problem with this, please contact me.
Differences of opinion regarding objective vs. subjective and functional capacity account for the majority of unfair denials that occur with private disability. It’s well worth paying attention to.
