When a person is unable to work due to a disabling injury or medical condition, obtaining benefits under an individual disability income insurance (IDI) policy or a group long-term disability (LTD) insurance policy is of a major concern for financial stability. The claims process is often foreign for disabled claimants. Filling out the forms and continuing to receive medical tests and treatment often seem like the only steps a person needs to take to obtain LTD benefits for a valid claim.
The insurance companies, however, are not necessarily going to accept the opinions of the claimant’s treating doctors at face value. Medical doctors employed by the insurance companies who have never treated, or even spoken to the claimant or the treating doctors review not only the claim forms, but also the entire medical file. Your doctor’s notes compiled during the course of treatment are part of the medical evidence being considered. For that reason, it is critical to work with your doctor to help insure that the medical file is complete and documents all relevant symptoms and clinical findings.
The initial decision from the insurer does not mean benefits will continue
The initial decision to provide or deny benefits is not the only friction point in the process. Many disabled individuals who initially qualify for IDI or LTD benefits are stunned to subsequently receive notification that the insurance company has decided to terminate coverage – even when their doctors say they are unable to return to work.
The insurance companies periodically review the medical records to find changes that they deem show that a worker is no longer disabled. They may contact your doctor for additional information periodically in the months and years that you remain out of work. They may also request additional information from the claimant, and a failure to submit the information may result in denied or discontinued benefits.
Often, patients are not aware of what information is contained in their medical records. It is vital to communicate openly and fully about your medical condition while receiving LTD insurance benefits; and it i equally as important to make sure the doctor understands how your medical condition interferes with your ability to do your job.
When speaking with a doctor, especially a doctor with whom you have a long-term and trusting relationship, it is often tempting to say that you are doing well, even when your condition has not changed, or may have even deteriorated. The common theme here is that in the doctor-patient relationship, you may feel that you are saying you are doing fine—considering the pain and other circumstances, but it is of critical importance that you communicate your symptoms and other issues of concern that are keeping you from working.
Test results, examination records and your treating physician’s ongoing evaluation and diagnosis of the objective medical evidence are all critical at every stage of the process. If you do not explain your current symptoms and ailments during a check-up, your doctor may enter a note in the file that you have no current complaints of pain – even though the doctor may still feel you are not able to resume full-time work. The insurance companies likely will highlight any note suggesting improvement or a lack of current symptoms as a reason to terminate benefits unjustly. Consulting with a lawyer who has a strong command of LTD insurance coverage issues and familiarity with the type of information that needs to be included in medical records will help you to get the benefits you are entitled to receive.
