Every disability insurance benefit claimant needs to have a doctor certify their disability to the insurance company as a condition of receiving disability benefits.  Treating doctors fulfill a critical role in conveying information to the insurance company about the claimant’s diagnosis, treatment, and how their patient’s condition affects their ability to work.  But is a doctor enough? Not necessarily.  Often, the patient needs to seek out the right kind of doctor, a specialist doctor, to convince the insurance company that a condition is disabling.

Specialists Versus Non-Specialists

In nearly all circumstances, the insured should be receiving treatment from a doctor who is a specialist in the condition or type of condition that is causing the claimed disability.  Here are some examples:

  • Insurers are dubious of disability claims involving mental health conditions if the claimant is not seeing a psychiatrist. While family practitioners and internists can prescribe psychiatric medications, psychiatrists are specifically trained in and focus their practices on prescribing such medications and treating mental health conditions.  Relatedly, someone who is receiving treatment from a psychotherapist only is unlikely to have their claim approved since insurers may presume the illness is non-severe if no medications have been prescribed by a psychiatrist.
  • Also related is that claimed cognitive impairments may need to be assessed by a neuropsychologist who administers standardized neuropsychological testing, the gold standard for diagnosing cognitive impairments and assessing their severity.
  • Court decisions have explicitly stated that the type of doctor who is in the best position to diagnose and treat fibromyalgia is a rheumatologist. Rheumatologists are also the ideal providers for other rheumatologic and auto-immune disorders, although gastroenterologists are the appropriate specialists for auto-immune conditions affecting the digestive tract such as Crohn’s disease.
  • While a general neurologist is appropriate for conditions such as Parkinson’s disease or multiple sclerosis, claimants should be seeing a subspecialist neurologist such as a movement disorder specialist for Parkinson’s disease. Claimants suffering from MS should also be seeing a specialist for that disorder if one is available nearby.
  • Similarly, for cancer-related disabilities, if at all feasible, the patient should be seeing an oncologist whose practice is focused on treating their type of cancer.
  • Cardiologists also practice in sub-specialties, and it may be necessary to consult with an electrophysiologist for an arrhythmia, tachycardia, or other cardiac disabling conditions.
  • Orthopedists also practice in sub-specialties; and seeing a subspecialist who focuses on particular parts of the body such as hips, shoulders, or spine will often be more persuasive to a disability insurer than a general orthopedist. For spinal impairments, depending on the nature of the impairment, a neurosurgeon may be more appropriate than an orthopedic surgeon.

Other Guidelines for Strengthening Your Disability Insurance Claim

Other considerations that may enhance a disability claim are the following:

  • Physicians who are affiliated with teaching institutions and who hold academic rank may carry more weight with insurance companies than other doctors.
  • Experience matters. Doctors who have extensive experience treating particular conditions have greater authority than doctors who may be more generalists. For example, long Covid patients are likely to have better outcomes with their disability claims if they are receiving treatment from doctors who practice in clinics that are specific to treatment of long Covid.  However, while there may be value in pursuing novel and unproven treatments, long Covid clinics that are affiliated with teaching institutions or well-established healthcare systems are likely to be a better choice than seeing a physician who is a self-proclaimed long Covid expert.  The same guideline applies to other conditions as well.

In general, disability claimants need to anticipate that their claims may face resistance from the disability insurance company.  Resistance may be even stronger if the claimed disabling condition is one that cannot be specifically confirmed by laboratory testing or radiologic imaging.  Since the patient’s credibility is so critical in such cases, it is important to receive care and treatment from a doctor who knows what tests to run and who can best interpret test results and examination findings.

The Role of an Attorney in Managing Your Claim

Disability insurance claimants may wonder what role an attorney might or even should have in the selection of a doctor or other healthcare professional.  First and foremost, while there are some attorneys who are also physicians, most attorneys are not doctors and should have no say in their clients’ care and treatment.  It is not the attorney’s role to recommend a treatment, a medication, or a procedure for their clients, just as it would be inappropriate for a doctor to recommend a legal course of action.

However, a disability benefit claimant who is either just beginning to contemplate filing a claim, or whose disability claim has been denied, should consider hiring an attorney for advice on whether there might be other types of healthcare professionals they should be consulting to better assess their condition and offer beneficial treatment.  The lawyers at DeBofsky Law are experienced in handling disability insurance claims and can often make suggestions about the type of healthcare professional who could best document their claim and enhance the likelihood of success in appealing the denial of benefits.

 

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