doctor visits and ltd

How do your doctor visits and long-term disability go together?

Discussions with your doctor often include the reason for your visit, how you’re doing overall, and treatment plans.  The more issues or ailments you suffer from, the more in-depth these conversations tend to be.  It’s surprising then, how often we learn that clients have never discussed their disability or disability insurance with their doctors.

Talk to your doctors about your disability insurance

You should let your doctors know what you’re going through with the disability insurance company.  Aside from the obvious importance of making sure your doctors and medical records are added to your claim, your doctors should be aware of your financial situation and many will work with you if you cannot afford to pay co-pays or in the unfortunate event you lose your health insurance.  If they don’t know about it, they cannot help you.

Don’t limit your discussions to only one doctor 

Simply because a doctor isn’t a specialist for the conditions for which you are seeking disability benefits doesn’t mean that you shouldn’t discuss all your medical conditions with them, including conditions for which they don’t treat you.  These conditions should still be noted during your visit, and sometimes doctors can concur with other doctors, regardless of their field of specialization.  In any event, you don’t want the insurance company to look back at a visit and point out that you never mentioned something was bothering you (a common practice), when you omitted it because it wasn’t the reason for your visit to that doctor at that particular time.

It may cost time, or more, in the end

Remember that not discussing all your medical conditions and disability insurance benefits status could reduce the treating physician support you may need to have your claim approved or win your appeal.  It can also result in the need for additional visits to the doctor to specifically discuss your disability when paperwork must be completed or when your doctors are contacted by the insurer.  We sometimes get a response from doctors that the patient never discussed their disability insurance claim with them during a visit and will need to see them again to go over the requested information or forms that need to be completed.

Why visits with your doctors are important

It may come as a surprise, but a doctor stating you’re unable to work and scheduling a follow up visit in six months doesn’t always satisfy the insurance company.  Some insurers may want to see more continued care and ongoing treatment.  Even though there might not be much to do at a three month follow up visit besides a discussion with the doctor, a disability insurance company can view six months as too large of a gap without treatment.  Even if your benefits have been approved, regular visits to the doctor may be helpful in keeping your benefits from being terminated.  If your doctor doesn’t feel that you need to be seen more often, having the doctor explain why in the medical records may be helpful.

Other Considerations

Our office has absolutely nothing against a physician assistant or nurse taking part in a patient’s care or treatment.  However, when a file is being reviewed by an insurance company, or even a court, the opinions of a doctor may be weighed more heavily.  This may be especially true if the insurance company sends your file for review to a medical doctor and their doctor argues against your treating providers, who are not medical doctors.  If you are receiving disability benefits, you should make sure you occasionally have visits with a doctor instead of always seeing a physician assistant or nurse, and if you’re trying to fight for your benefits, you will probably want to have all of your visits with a doctor if possible.  

Insurance companies conduct file reviews for LTD

Insurance companies will often conduct a review of files to see if they believe a claimant is still disabled, or better said, if they think they should still be paying a claim.  Remember that most insurance companies’ primary goal is profitability (this is actually an ethical obligation for most corporations.)   Therefore, claim managers will often be expected to conduct a file review.  Think of it like an audit.  The insurer reviews the file to see whether ongoing benefits are warranted.  This can happen bi-annually, quarterly, or even monthly, depending on the carrier and its internal rules and guidelines.  Another common time files are reviewed is when the files are transferred from one claim manager to another.  

As an example, it is quite possible that your disability claim file is usually reviewed bi-annually, or twice per year.  Your claim just came up on six months and your claim manager conducted a review.  You and your doctors did everything necessary to get the review completed and the claim manager approves the claim for ongoing benefits.  However, one month after completing the review and approving the ongoing benefits, your claim manager leaves the company or gets transferred to another department and a new claim manager is assigned to your claim.  Rather than reviewing or relying on the review from the previous month, the new claim manager is instructed to conduct a fresh review on all files they just took over.  Now you and your doctors have to go through the review process all over again just one month after having just done it.  This actually happens from time to time.  

What happens during a disability insurance file review?

When your file is reviewed by the disability insurance company, they are reviewing to see if you meet the standards and definition of disability according to your disability insurance policy, plan documents, or contract.  Put another way, the insurer is reviewing whether it is still contractually obligated to pay or continue paying your disability benefits.  The steps, process, and requirements vary from carrier to carrier, and also depend on whether you have already been approved for disability benefits or are on initial review.

For this discussion, we will assume you have already been receiving benefits and the insurance company is simply doing a file review.  The insurance company begins by looking at your job duties, description, and classification to see what restrictions and limitations would preclude you from performing your own occupation or any occupation, depending on how long you have been out of work (most long-term disability policies pay two years for disability from one’s own occupation, then transition to an any-occupation disability definition).  The insurer will also request medical records from your doctors.  Always remember that while the insurance company may send out medical record requests, most disability insurance policies place the responsibility for providing medical evidence of disability on the claimant.  The claim manager may also send out forms for your doctor to complete that list your disabling medical conditions, restrictions and limitations, and reasoning as to why you cannot work.  It may become tedious for your doctors when it happens too often, and some may question the need for it, but if the insurance company requests documentation and does not receive it, a termination of benefits can follow.

Sometimes during a review, the insurance company may send a private investigator to conduct surveillance on you and your home.  The insurer can also schedule a medical examination for you with a doctor it selects, or send the file to one of their doctors to review and render an opinion.  The insurance company may decide at any point in this process, or once everything is concluded, that they no longer find you meet the definition of disability and deny your benefits.  

What if all else fails? Contact a disability insurance law firm

Sometimes, even when you have discussed everything with your doctor, they may not be willing to do disability insurance paperwork.  And even if they completed the paperwork, your claim could still be denied.  The insurance company may rely on how their doctor interpreted labs, testing, records, or results, and decide that you are not disabled or that your restrictions and limitations don’t necessarily preclude you from performing the tasks of your job, even if your doctors are supportive and have said you cannot work.  The insurance company may also deny your claim if insufficient records or requested information hasn’t been received.  If you have been denied disability insurance benefits, contact us online or give our office a call to see if we can help you get the benefits you deserve.  The information in this BLOG may not be all inclusive of the situation, events, or circumstances surrounding your case.  If you have a denial letter, our office can review it and conduct an interview with you to get the facts specific to your case.  Call us at 813-839-2000 (813-839-2000).