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No Doctor Shopping Allowed

This subject is going to be a little touchy and I can already see some of my readers getting a bit miffed. It’s still and important topic for all insureds, and listening to this article could save your claim. So, I’ll take the heat.

First let me say that consulting multiple physicians with many specialties is normal for any disability claim. No disability is so unique that only one physician is usually required. So, it’s normal and customary for insureds to have one or many physicians managing any given disability. But, I’m not writing today about what’s normal, I’m writing about what’s not.

I’ve been seeing certain characteristics with claims that is quite disturbing. While it’s perfectly acceptable to see “referred” physicians with specialties, it is not normal for insureds to consult with one physician after another “in search of new diagnoses that “will make them co-morbidly impaired.” It appears that some insureds “think” that the more diagnoses they have, the safer their claim is, and that’s simply not true. In fact, it’s exactly the opposite.

Let’s start at the beginning. In my career I’ve had this come to mu attention on more than one occasion. An insured sends me a list with maybe 20-30 diagnoses on it. It lists Lyme disease, MS, cardiac issues, FMS, CFS, Lupus and many other potentially serious diseases. If you look at this list in terms of disability, it’s clear that if this insured really had all of the listed diagnoses, he/she should either be in Intensive Care, or in a Hospice.

Now, please keep this in the back of your mind for a moment. Next, we have a person who reads every article to be had from the Internet about certain diagnoses that mysteriously jump off the computer screen right into his/her body and claim. The problem now is, convincing physicians to document whatever diagnoses the patient wants, and that can be a hard task. Multiple appointments are made with varying credentialed physicians and the insured is kept busy with consultations until he/she gets the documentation they want. Now, they may be ready for the Hospice!

Insurance companies aren’t stupid. They are well aware of the “I have everything phenomenon” and either regard these insureds as mentally impaired, or deliberately intending to fraudulently seek out diagnoses for the purpose of secondary gain. Neither one of these perceptions is a good thing.

Primary care or treating physicians should be the only ones who diagnose disease, and only as the result of “objective evidence, or, the result of a treating history of observation and clinical examination. Insureds SHOULD NOT attempt to “talk their physicians into” any disease they THINK THEY HAVE. Surprisingly, while most doctors recognize the drill, there are some out there who, in order to make the problem go away, will just document whatever the patient wants. (A real cause of the insurance company’s paranoia with over restrictions.)

Presenting many diagnoses to insurance companies as proof of disability discredits all of the diagnoses.Think about this for one moment. Most multiple diagnoses are in some way related to one or several primary diagnoses. For example, joint disease, severe fatigue, (all with separate ICD-10 codes) is related to a primary diagnoses of FMS, and several other diseases. Totally unrelated multiple diagnosis, don’t occur all that frequently. It is a dangerous game to play with a claim that could be denied with multiple diagnoses.

Disability claims should list diagnoses that preclude people from working. While some might say ALL diagnoses prevent work, that’s really not true since having a diagnosis does not equal a disability claim. There are many people diagnosed with disease who continue to work, including some of the more serious diagnoses.

Insureds should report symptoms to their physicians and allow them to make the diagnosis and recommend treatment. There is no “gain” to reporting any diagnosis you can convince a doctor to document. That ship has sailed a long time ago and insurance companies will discredit claims if “doctor shopping” is evident.