In order to continue to receive benefits in 2023 ALL of the following criteria must be met. If not, claims will be considered vulnerable to risk management and denial. It might be a good idea to consider whether your claim would benefit from an expert. If so, please feel free to call me.
There must be a clearly documented primary diagnosis. There are times when despite all diagnostic measures taken, physicians really don’t know what’s wrong with you. Generally, treating physicians will conveniently throw you into a category that is difficult to support such as, Lyme disease, MS, FMS, CFS, chronic pain and a whole host of other somaticized complaints that you may or may not have. Disability insurers will not pay claims lacking a documented primary diagnosis, preferably one that is NOT self-reported. If you doctor doesn’t know what’s wrong with you, your insurance company won’t either, and they won’t pay.
All insureds must be prepared to prove at least a 20% earnings loss. Although this mostly pertains to IDI insureds, the rules are clearly stated in most policies and Plans that there must be at least a 20% earnings loss from pre-disability earnings. Own occupation “better than sliced bread” policies promising total disability may not apply. The earnings loss must be evident in tax returns.
Specific medical information will need to be documented on physician forms to include: primary and secondary diagnosis, prognosis, statement about MMI (Maximum Medical Improvement), statement that the frequency of treatment is appropriate, medical restrictions and limitations, treatment plan, and statement as to whether exercise is recommended. If this information is not communicated to the insurance company on a regular, repetitive basis, it is unlikely claims will be paid long-term in 2023.
Most insureds believe their docs do a great job, but most do not. If the above information is not forthcoming, and isn’t placed in the file, you and your physicians are likely to see increased harassment until either the information is given, or claim is denied. The more complex or indecisive your claimed disability is, the more likely the claim is targeted and vulnerable to denial.
All medical information that can possibly be obtained must be added to your file. Insureds should always consult physicians with the best credentials they can afford. While it is not necessary to treat with specialists all the time, physicians must be Board Certified in their specialties. Credentials of treating physicians are considered and an updated Curriculum Vitae of your treating physician should always be in the file.
All physicians who have treated you within the last 12 months for your claimed disability must be listed on a physician’s contact list (of some sort) and added to your file. Update forms should include all NEW physicians, and prior Physician Contact Lists should include all physicians who have treated you for your claimed disability within the last 12 months.
Curriculum Vitae for all treating physicians should be added to your file. All physicians have the CVs just for the asking.
Insureds should NOT exceed reported medical restrictions and limitations. Some insureds believe that R&Ls are only for update forms, but once reported, are not necessary to adhere to. It is likely increased and more sophisticated surveillance will take place frequently in 2023.
ERISA Administrative Files and IDI files should be periodically updated with as much information that can be obtained supporting disability. Insurance claims handlers are required to “touch” claims every 30 days, and, as a result a great deal of paperwork is added to disability files outlining why claims should be, or are planned to be, denied. Therefore, insureds need to do the same thing. Specific, relevant information can be downloaded from the Internet and sent to insurers to further support claims. Additional medical forms and physician reports can be added at any time. Objective testing other than “normal” results can be added as soon as possible. Adding, or supplementing files is extremely important for ERISA claimants. “Self-reported” impairments should ALWAYS include a properly organized set of journal records preferably signed by the treating physician. Self-reported impairments are those for which there are no diagnostic tests that prove you have what you and your physicians say you have. Therefore, it will be extremely important in 2020 for insureds to keep journal pages or spreadsheets documenting symptoms, severity, duration, date, and time. Migraine claims, the number one most frequently denied claim in 2019 is a good example. FMS, CFS and Chronic Pain are other self-reported impairments that should be journaled.
Activities of Daily Living should ALWAYS be documented in the file. There are only five ADLs: Dressing, Toileting, Transferring, Food Preparation and Cognition, sometimes Continence. The extent to which an insured is ADL affected should always be documented and signed off on by the treating physician. This is because anyone considered ADL affected in 2-3 areas is always considered more disabled than if not affected at all.
IDI insureds must file claims in a timely way. Waiting months, even years to file on IDI polices is an unnecessary vulnerability. Discussions and communications for “late filing” and “prejudice” will always be used against insureds for various reasons.
Only ONE validated signed Authorization outstanding at a time. Insureds should never sign multiple insurance company Authorizations valid at one time. Wait until the current one expires before signing another one. This does NOT include facility specific Authorizations.
Here is a list of probably claims that will be targeted in 2023 by all insurers in the order of priority:
Claims with large monthly benefits, i.e. in excess of $3,000/month. Claims greater than $5,000/month never get off the target list. This includes IDI claims with Lifetime benefit duration. This is referred to internally as, “The biggest bang for the buck.”
Claims for disability with “self-reported” impairments will remain on the insurance target list, and will receive the largest cost-added investigation referrals. Popular targets are migraines, Fibromyalgia, Lyme disease, Chronic Fatigue Syndrome, HIV, Cognition, and mental illness.
Claims with missing medical restrictions and limitations.
Claims of insureds who are working part-time and are paid residual earnings.
Claims with suspicious surveillance and/or telling social media results.
Claims with inconsistent documentation that doesn’t make sense.
Claims nearing “any occupation investigations” anywhere from 9-18 months of paid benefits.
Claims with unresolved SSDI applications/overpayments etc. In 2019, we saw insurers focusing on SSDI awards and endless recalculations.
Continuing in 2023, insureds and claimants will notice a change in the aggressiveness and frequency of communications from all disability insurers. Letters may be written in new threatening ways for the purpose of “scaring” insureds enough to be compliant with whatever is asked for.
There will be increased demands for field visits and Independent Medical Evaluations. Surveillance is expected to hit all time high as insurers attempt to “catch” insureds exceeding medical restrictions and limitations.
Policy and plan provisions will be enforced to the letter. By the way, most of what I’ve described above IS required of claimants and insureds as part of their contracts anyway.I suspect in 2023 there will be less leniency with time limits and paper requests.
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