Disability Insurance Company Claim Reviews – What Are They Looking For?

Throughout the time claimants are eligible for disability benefits and benefits are being paid, claimants are intermittently advised that their claim is being reviewed and that updated information is required. This often indicates that the insurance company is scrutinizing the claim to see if there is evidence that can be used to suggest that the insured has improved enough to return to work. These requests for updated medical information may be made directly to the insured’s treating physician(s) who do not have time to draft a detailed response to the numerous questions on the form being sent to them and/or who do not have the time to speak with the insured’s consulting physician, who tends to call during peak business hours. Updated records are requested from doctors and the insured receives forms to complete. In certain cases, the insurance company has conducted surveillance and seeks additional information from the insured and their doctor(s) in order to obtain “clarification” about the activities seen on surveillance and the insured’s reported limitations.

As we all know, medical records do not always contain many details from a patient’s visit and often include language such as “the patient presented today with complaints of back pain/neck pain, etc. but in no acute distress.” The fact that a patient limped into the office, had difficulty getting on the exam table, was in obvious pain, and had observable limitations is not necessarily noted in the records, especially by a physician that is familiar with their condition and has been treating them for years. Unfortunately, insurance companies take this lack of information and interpret it to mean that the patient is fine and not functionally limited. Attempts by the insurance company’s consulting physician to contact the claimant’s treating physician for clarity are insincere in that the insurance company’s doctor calls in the middle of the day when the other doctor is likely not to be available. Moreover, the insurance company doctor does not attempt to schedule a phone conference with the claimant’s doctor or offer to pay for the doctor’s time, despite the fact that the doctor will have to give up appointment time to speak with the insurance company physician. The forms sent to treating doctors can be lengthy and require a great deal of time to complete. As such, many physicians either don’t return them or complete them quickly – simply noting that their patient remains unable to work.

The insured is also given a set of forms to complete with detailed questions about their medical conditions, daily activities, work history, and current treatment. Often times this is sent after they were seen on video surveillance. While going to the grocery store, running errands, taking out the garbage, and walking a dog are most certainly not evidence that someone can return to work full time, the insurance company attempts to use the ability to function in any capacity as evidence that the insured is exaggerating their claim and stated limitations and can return to work. Additionally, the insurance company may have accessed their insured’s social media accounts and will interpret a smiling picture from a friend’s wedding or a night out to dinner as “proof” that the insured is fully functional. What is not presented in the social media photo is the amount of pain felt or level of exhaustion experienced during or after the picture was taken. While most people know that a Facebook or Instagram photo is meant to present a person at their best, insurance companies attempt to use these smiling photos to their advantage.

Understanding the tactics employed by insurance companies to create the appearance that their claimant is no longer disabled is important. Forms completed by the insured need to be detailed and clearly explain what they can do, what they cannot do, and how they feel after a day of activity or hours out of the house. Making sure the insurance company is given accurate information that thoroughly explains the insured’s limitations, daily activities, good days, and bad days can make the difference between staying on claim and having benefits terminated. Just as important is the need for the doctor’s form to provide information explaining how their patient’s medical conditions do and do not limit them and why they remain unable to work efficiently, effectively and with continuity. At Disability Insurance Law Group, we have successfully worked with our clients and their physicians to make sure the insurance company has ample evidence of their disability and cannot misinterpret what they review or observe. If you have any questions about your disability claim, please feel free to contact us at 954-989-9000 or www.dilawgroup.com for a free consultation.