Every claim for disability insurance benefits requires the completion of three forms – the claimant’s statement, the employer’s statement, and the attending physician’s statement certifying the claimant’s disability. The claimant’s statement notifies the insurance company about what the claim is about and why the claimant is asserting an inability to work. The employer’s statement (or for individual disability income insurance claims, the portion of the claim documentation that describes the claimant’s employment) furnishes information about the claimant’s work – the nature of the job, the job duties, and the claimant’s salary or earnings. Finally, the attending physician’s statement is critical because it furnishes a diagnosis and explains the claimant’s restrictions (what the claimant cannot do) and limitations (what the claimant is limited in doing) in order to help the insurance company, determine whether a condition is serious enough to preclude working. It is important to keep in mind that a diagnosis alone is not a disability. Disability is based on how symptoms and functional restrictions and limitations impair a claimant’s ability to perform the duties of either their own job or any job depending on how the policy defines the term “disability.” So naturally, your treating doctor plays a key role in your the claim process.
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Enlisting the Treating Doctor’s Assistance
It would be a mistake to file a disability claim without first discussing the anticipated filing with the appropriate treating doctor. In most instances, the treating doctor who needs to certify disability is that specialist who is treating the main disabling impairment. But sometimes there is more than one disabling condition – in such situations, it may be appropriate to submit two or more treating doctor statements. In other circumstances, the primary care physician would be the appropriate doctor to certify disability because that doctor is likely to know the most about the claimant’s overall condition.
Do’s and Don’ts Relating to Treating Doctor’
There are certain key issues that need to be discussed with the treating doctor who is certifying disability. Those issues include:
- Is the doctor recommending that the claimant stop working? If not, filing a disability claim may not be in order.
- What is the date of disability? Timing can be critical, especially if the claimant has a chronic condition they have been battling for a lengthy period of time or if the claimant is no longer working. If the treating doctor is certifying disability for someone with a chronic illness, it is important to document any new symptoms or recent changes that have triggered an inability to work. If that is not done, the disability insurer is likely to raise concerns about how a condition that had been diagnosed in the past suddenly became disabling when the claimant was able to work for a significant period of time after receiving the diagnosis. If the claimant has unilaterally stopped working, will the doctor certify that the disability began when the claimant was last actively at work? If not, there may be a problem establishing disability, especially if the claim arises under a group long-term disability insurance policy, since benefits end when the employee is no longer active at work.
- What are the claimant’s job duties? The treating doctor needs to understand what the claimant’s job consists of to convey how the condition causing impairment limits the claimant’s ability to perform that job. This includes a discussion of both the physical duties required to perform the occupation, as well as the mental and cognitive duties of the job. Most doctors are not trained to perform fitness for duty job evaluations, but the only way the doctor can correlate a patient’s symptoms and limitations to a specific job is to know exactly what the claimant does at work.
- What is the anticipated length of disability? If the impairment causing disability is transitory or is expected to improve quickly with treatment, it may not qualify as a disabling impairment for more than a short term.
- What are the potential risks and benefits of potential treatments? If the claimant needs to undergo an invasive surgery, the claimant has the right to forego such treatment, and the insurance company cannot demand that the claimant undergo invasive and risky surgery as a condition of receiving benefits. On the other hand, if a recommended treatment has a high likelihood of success and low risk of complications, the claimant would be unlikely to qualify for benefits. Likewise, if the impairment may be ameliorated with medications, the claimant would not be deemed disabled unless the medications had been tried and failed to produce improvement.
While a patient expects assistance and cooperation from their treating doctor, claimants should not ask their doctors for the following:
- Do not ask the doctor to support a disability claim that the doctor is uncomfortable supporting. Doctors need to offer their support freely, and the information they provide to the insurance company needs to be consistent with their medical judgment and opinions. The information conveyed in the attending physician statement also needs to be consistent with the documentation in the doctor’s records which the insurance company is certain to request. In some situations, doctors simply make it their practice not to complete disability forms. If that occurs, it may be prudent to get a second opinion from another doctor, but “doctor shopping” is a red flag for insurance companies.
- Do not ask the doctor to write a letter stating the claimant is “disabled.” The insurance company makes that determination and doctors may have a different understanding of the meaning of “disabled” than the policy definition. Also, words matter, especially the word “sedentary.’ A doctor may deem their patient limited to sedentary activity; i.e., spending their days at home in bed or in a comfortable chair or recliner. But insurance companies view the term sedentary to mean working at a desk job where the worker is seated for most of the day, usually working on a computer and phone.
- Be respectful of the doctor’s time and do not pressure a treating doctor. It is often a good strategy to have the doctor complete the attending physician’s statement during an appointment or scheduling a separate appointment for that purpose so that the patient can explain to the doctor how their condition interferes with their ability to work. Seeing patients and completing electronic medical records takes up the overwhelming majority of a doctor’s day. Since the insurance companies will not pay doctors to complete attending physician statements, the patient needs to be respectful of the doctor’s time and availability.
Conclusion: Your Treating Doctor Plays a Key Role in Your Disability Insurance Claim
The treating doctor fulfills an essential role in a disability insurance claim. Discussing the claim honestly and tactfully with the treating doctor is likely to lead to the best outcome and strongest support for the claim from the treating doctor.