At Dell & Schaefer, we’ve been contacted by many disability claimants whose claims have been denied. Over the years, we’ve seen just about every possible basis for a disability benefit denial – and one of the most frequently-seen reasons involves the disability insurance carrier’s paper review and independent medical exam or evaluation (IME). Below, learn more about how this part of the process may lead to claim denial, as well as what claimants can do to avoid having their disability claim denied.
Paper reviews and medical exams conducted by disability insurance companies are the number one reason for long term disability denial.
Your claim for long term disability benefits is essentially just a hefty paper file – so the disability insurance company will conduct a paper review. Unfortunately, while many of the paper records in your claim file are generated from (and based on) in-person interactions with your doctor and other medical providers, the insurance company’s paper review adds another layer of distance. This review will decide whether your records support a claim of disability without ever seeing you in person, talking to your doctors, or reaching out to others with first-hand knowledge of your disabling condition and how it affects your ability to work.
Your disability company will have their own nurse, in-house doctor or an outside company review your medical records and make a determination if you are disabled or not.
One part of the paper review process involves a doctor, nurse, or third-party medical provider reviewing your medical records to see whether they support a disability determination. Again, this review can be problematic because it relies on someone else’s assessment of a dry record; the examiner will attempt to second-guess your medical provider’s conclusions without seeing you in person. And because the examiner is employed by (or contracted with) the disability insurance company, claims that have any wiggle room at all are more likely to come down in the insurance company’s favor, not the claimant’s.
It’s frustrating that disability insurance companies attempt to rely on paper file reviews when they would never accept your claim if you were never physically examined by a doctor.
As shown by the COVID-19 pandemic, which prompted an increase in telemedicine appointments (leading to a steady stream of claim denials), disability insurance companies aren’t often willing to accept a disability determination from a doctor who has never seen the claimant in person. But this is exactly what happens during the paper review process – the insurance company decides whether you’re disabled without ever examining you in person. One exception to this is the independent medical exam, discussed in more detail below.
Not every doctor hired to examine you by a disability insurance company is a hired gun, but you need to do research before agreeing to be examined by the doctor chosen by your disability company.
If the disability insurance company isn’t fully satisfied with the evidence presented in the claim file (or created during the file review), it may order an independent medical examination to be conducted by a doctor of the insurance company’s choosing. Before agreeing to be seen by the insurance company’s doctor, it can pay to do some research. Doctors who don’t have their own independent practice and only see patients who are referred to them by the disability company are far more likely to be in the insurance company’s pocket, so to speak.
The third party companies that hire doctors to review your medical records or hire doctors to examine you are usually biased toward the disability company.
Again, because these outside companies and the doctors and nurses are contracted with are hired (and paid) by the disability insurance company, the scale is often tilted a bit in the insurance company’s favor. To even things up, you’ll need to ensure two things: 1) your questionnaire responses are truthful, without exaggerating or overstating your symptoms; and 2) your other medical evidence is strong.
If you are asked to respond to a doctor’s report generated by your disability company, the reply must be strategic based upon the stage at which your claim is at.
If the IME or claim file review is unfavorable, you’ll have an opportunity to respond to it. This is a very important point in your claim – if you don’t submit a response or if your response doesn’t hit all the relevant points, the insurance company may reject any arguments you raise later, claiming that it already gave you the chance to dispute its conclusions and you didn’t. Your response must be as complete as it can be, going point-by-point through the report and noting any inconsistencies or errors.
Because the IME response is so important to the future of your claim, it’s crucial that you have legal support throughout this process. The attorneys at Dell & Schaefer have helped thousands of claimants overcome unfavorable IME reports, and we can help you too. Just give us a call today to discuss your claim with one of our experienced attorneys.