I know I must be sounding like a “broken record” when it comes to articles about providing good, solid, medical proof of claim. But, I’m seeing, and hearing about more and more denials from insurance companies citing lack of medical information, or, medical information insufficient to prove inability to work.
“Disability” defined for claim purposes has an entirely different meaning than just “medical disability.” Insurance “disability” essentially means “inability to work”. It isn’t about your pain, or fatigue, or even how systemically sick you are. Insurance companies just want to know WHY YOU CAN’T WORK TODAY. They especially don’t want to know why you couldn’t work yesterday, but only why you can’t work today, and in the future.
Many insureds keep making the same mistake of sending “old news” to support future claims. Your insurer doesn’t care about why you couldn’t work in the past, because they’ve already accepted that proof and paid your claim in past periods. In order for disability to CONTINUE TO BE PAID IN THE FUTURE continuous medical proof of WHY YOU CAN’T WORK TODAY must be provided. Sending in old patient notes and and lab reports, while proof enough 6 months ago, isn’t sufficient proof for today.
Second, your physicians are NOT the sole determiners of disability status.”But, my doctor said I couldn’t work!”, or, “My medical says I’m totally disabled.” Your physicians don’t decide your claim status, far from it.
Medical certification by a treating physician is reviewed by internal insurance reviewers who render written opinions as to whether they agree or not. If there is disagreement, the insurance company calls your physicians to try and convince them to change their mind. If they do not, insurers will then have your medical reviewed by a second internal physician, who if he/she wants to keep their jobs will never disagree with the first reviewer. This can get a bit silly; I just reviewed a Unum denial letter where there are at least 4 internal doctors who reviewed the most recent patient medical opinions and still denied the claim.
ERISA folks have the “deck stacked against them” coming out the gate. The culprit is called “discretionary authority”, which gives insurers the complete authority to decide who gets paid and who doesn’t.
In theory, “discretionary authority” is supposed to be tempered with “fiduciary duty” and “good faith and fair dealing”. If the last 20 years have proven anything, it’s that insurance companies are incapable of policing themselves to give insureds a fair break. The trend is still to deny legitimate claims and bolster profit whenever possible.
I’m hoping that readers will now understand why I write about the importance of good medical and proof of claim. By GOOD MEDICAL, I mean your physician’s ability and skill to link your medical condition to logical functional incapacity for work. CAREFUL HERE. MEDICAL PROOF OF CLAIM THAT DOES NOT LINK MEDICAL DISABILITY WITH INABILITY TO WORK IS USELESS.
For example, doctor writes, “Patient is unable to work due to severe pain.” Better said, “Patient is unable to perform occupational tasks involving lifting >20 lbs., or, standing >10 minutes without breaks.”
DCS, Inc. has recommended to insureds for years that they provide their physicians with copies of their Job Descriptions and point out certain tasks that they can’t do. Talk about it, give your doctor something to write about. I guarantee you, physicians aren’t going to spend much time pondering their responses, particularly on forms. Physicians aren’t mind readers, talk to them and be frank about “where it hurts.”
Stop thinking of your physicians as the sole determiners of your disability status, THEY ARE NOT. If you were playing a game of Texas Hold’em and knew the deck was stacked what would you do? Hopefully, you wouldn’t play that game.
If you concentrate on working with your physicians to provide the best possible medical proof of claim possible you will “unstack” the deck and give your claim a fighting change of success.
