It comes to our attention there is a great deal of misconception concerning the role of internal physicians and what they actually do. The more serious misstatement of fact I’ve heard in a long time is “Internal physicians make claims decisions.” If I were to make this comment to a Unum attorney, for example, I would be swiftly corrected. In fact, decisions to pay or deny disabilty claims are “business” decisons and are made by the “business departments” – that is, claims managers and directors. No internal physician consultant of any disability insurer will admit to making claims decisions BECAUSE THEY DO NOT.
If you read internal medical reviews carefully you may notice the physician NEVER documents the claim should be paid or denied. The insurance-paid physician documents: 1) the medical information indicates the insured has been “over-restricted by his own physicians; 2) based on the medical evidence submitted, there are no restrictions and limitations precluding work; 3) based on a review of the medical records the insured has (sedentary, light, medium or heavy) work capacity and 4) based on the medical information in the file, the restrictions and limitations either are or are not reasonable. That’s it.
You might ask, “so why are internal and outsourced insurance medical reviews so important?” Although I’ve written articles on the subject, I’ll mention it here again – Internal medical reviews create the illusion of fact to protect the insurer when adverse decisions are challenged by regulators and the courts.
I can’t tell you how many times claimants and insureds have told us, “I don’t know where Unum’s physician got that from”, or ” Prudential completely misstated what my doctor said. Even claimant treating physicians will tell DCS, Inc. “I never said that.”
Most internal medical reviews have absolutely nothing to do with medical facts indicated in the records, but rather “snatch” key phrases favorable to the insurer leaving out all else favorable to the insured. The goal or objective of internal medical review is to reposition, rephrase, interpret, and exaggerage patient medical notes to back-up or support business decisions to deny claims made by claims management.
This is where the term “rubber stamp” comes from because internal medical documentation is often sought AFTER a roundtable where the decision to deny the claim has already been made by the participants.
Decisions to deny disability claims are made by the “business elements” of the company and those who either have access to financial reserves, or who are accountable to executive management for “rolling in” reserve gains within a specific period of time such as month-end, quarter or year-end.
Another misconception I’ve heard lately is that medical claims decisions are made by non-medical people, nurses, and administrative personnel. No claim reviewed by Unum can be denied by management unless there is a medical review by a qualified physician in the file.
And some but not all Unum claims are reviewed by a highly qualified Medical Director. In the past, I have read a few court cases where RN reviews have resulted in claim denials and the courts decided in favor of the Plaintiff, thank goodnes.
Physicians aren’t qualifed to make claim decisions anyway. A decision to pay or deny a claim is based on a review of the provisons of the policy contract to determine if the insured meets eligibility requirements and the defintion of disability.
Physicians aren’t qualified to adjudicate disability contracts and make liability decisions. On occasion, physicians become savvy to the lingo, but have no training or speciality as contract specialists. Internal physicians are frequently cautioned NOT to cross their lines of expertise into the realm of contract law.
Insureds need to know how the process of disability claim review works and what the protocols are. Remember, internal insurance-paid physicians never make actual claims decisions. Although DCS is of the opinion insurance-paid physicians are physicians first, and employees of the insurance company second, insurance company physicians do what they do because its a much easier buck than running a busy practice. In any case, Unum’s internal physicians DO NOT make actual claims decisions, and alas the culprit is higher up in claims management.
