Tag Archives: fce

How Long Does It Take to Get Benefits? – Part 2

In an ideal world, you’d receive a favorable decision and your first benefit check shortly after your policy’s elimination period is satisfied.  Unfortunately, even wholly legitimate claims get scrutinized, questioned, delayed, and in some cases, denied.  Below are a few common reasons benefit payments are delayed, particularly at the outset of a claim.

1. Improperly Completed/Partially Completed Forms

If your initial claim forms are missing information, unreadable, or incomplete, your insurer will likely issue additional forms for completion or use the missing information as an excuse to delay processing the claim.  This applies to both the forms that you are required to complete and sign and the forms the insurer gives you to give to your doctor to fill out, so it is important to follow up with your doctor and make sure that all of the necessary forms are completed and returned in a timely fashion.  If you do not carefully document your claim, and you do not promptly respond to requests for follow-up information, most insurers will delay making a claim decision until you provide them with the requested information.

2. Pending Requests for Information

At the outset of your claim, your insurer will require you to sign an authorization that allows them to request a wide range of information from a wide range of sources, including your doctors and employer.  Oftentimes, the insurer will request information from these other sources (without telling you) and then will delay making a decision on your claim if any of these requests remain pending.

This means that even if you provide the insurance company with everything they requested from you, there may be other information that the company is waiting that is holding up the claims decision.  Consequently, it’s important to ask the insurance company to find out if there are any pending requests, adn then follow up with your doctors, employers, etc. as needed to ensure that the information is provided.

It’s also important to keep tabs on the pending requests, to determine whether the scope of the insurer’s investigation is appropriate.  An experienced disability attorney can advise you on whether a particular request for information is warranted under the circumstances of your particular claim.

3. Failure to Schedule Medical Examinations/Interviews

When you file a disability claim, insurers will almost always require that you participate in a detailed interview and/or undergo an independent medical examination (IME).  While the stated point of these requests is to confirm or verify your disability, they can often be an attempt by your insurer to discredit your own doctor or medical records and generate fodder to deny your claim.  Depending on the nature of your condition, your insurer might also request other types of interviews or exams—such as a functional capacity evaluation (FCE) or neuropsychological evaluation.

Some claimants (mistakenly) believe that if they keep putting off these exams, then they’ll be able to avoid the exams.  However, most disability policies contain a provision that expressly requires the policyholder to submit to exams, and states that failure to do so is grounds for denying a claim or terminating benefits.  So if you put off these exams, it’s only going to delay the company’s claim decision, and possibly result in a claim denial.  However, keep in mind that going into a medical examination, IME, or interview unprepared can be just as bad for your claim, so it’s very important to prepare beforehand.  Once again, an experienced disability attorney can advise you regarding the proper scope of an interview or IME, and can also be present for the interview or IME, if desired.

 

What is a Neuropsychological Evaluation? – Part 4

This is the last post in our series of posts about neuropsychological evaluations.  We will conclude this series by discussing (1) why an insurance company would ask for an exam, and (2) how a neuropsychological evaluation can impact your disability claim.

Why Would My Insurer Ask for a Neuropsychological Evaluation?

Unfortunately, it is way too common for an insurer to look for ways to deny a claim, even in the face of strong medical proof of a disability.  This can be especially true for conditions or disabilities that are more subjective than objective, or disabilities that include symptoms that cannot be definitely shown by commonly administered medical tests.  An insurer intent on denying a claim may use Independent Medical Evaluations (IMEs), Functional Capacity Examinations (FCEs), Neuropsychological Evaluations, or a combination of these three exams, in its efforts to undercut a policyholder’s own doctor’s evaluation and medical records (particularly if the policyholder’s treating doctor is supportive of the claim and has clearly indicated that the policyholder should not return to work in their own occupation).

As we discussed previously, the limitations inherent in neuropsychological evaluations may lead to a conclusion that you are less cognitively impaired than you truly are, and/or a recommendation that you are able to return to work.  Further, if the test is administered by a biased evaluator, results can be interpreted and manipulated in order to deny your claim.

What Can I Do?

First, make sure that your insurance company can actually require a neuropsychological examination under the terms of your policy.  Some policies include provisions requiring that claimants undergo “medical exams” or exams “conducted by a physician.”  If your policy contained this sort of provision, you could potentially argue that the insurance company cannot require you to undergo a neuropsychological evaluation, since a neuropsychologist is not a physician, and this sort of exam is not strictly a “medical exam.”

If you must undergo the evaluation, there are several steps you can proactively take to prevent the examination from unfairly complicating or jeopardizing you claim, many of which are similar to steps you should take before an IME.

  • Be sure to provide complete medical records.
  • Carefully fill out any intake paperwork.
  • Advise your medical team of the request for the evaluation.
  • Take notes, including what questions were asked during the interview portion of the evaluation.
  • Report back to your medical team after the test, especially regarding any negative effects, such as increased fatigue after the evaluation.
  • Request a copy of the report.

It is important to note that neuropsychological evaluations are not inherently biased or a poor indicator of disability.  In fact, they can actually be helpful in confirming your disability and demonstrate an impaired level of functioning that makes it impossible to return to work.  In some instances, you may wish to undergo an exam with a truly independent examiner, either proactively or as a follow up to one ordered by your insurer.  As with any new evaluation or course of treatment, you should carefully discuss this option with your current medical team and attorney, and obtain recommendations to a reputable evaluator.

Sources:

Atif B. Malike, MD; Chief Editor, et al., Neuropsychological Evaluation, Medscape, http://emedicine.medscape.com/article/317596-overview, updated May 18, 2017.

Neuropsychological Evaluation FAQ, University of North Carolina School of Medicine Department of Neurology, https://www.med.unc.edu/neurology/divisions/movement-disorders/npsycheval

Kathryn Wilder Schaaf, PhD, et al, Frequently Asked Questions About Neuropsychological Evaluation, Virginia Commonwealth University Department of Physical Medicine and Rehabilitation, https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwir3pKk__fUAhUBEmMKHenkDzsQFggoMAA&url=http%3A%2F%2Fwww.tbinrc.com%2FWebsites%2Ftbinrcnew%2Fimages%2FNeuropsych_FAQ.pdf&usg=AFQjCNG0Mv3o17ZrNmXuDN5ITUIh4fWYtA&cad=rja

What is a Neuropsychological Evaluation? – Part 2

In our last post, we looked at what a neuropsychological evaluation is, and how it can be used as a tool to identify cognitive impairments.  In this post we will talking about how a neuropsychological evaluation works in more detail.

What Can I Expect During a Neuropsychological Evaluation?

A neuropsychological evaluation will generally consist of (1) a review of your medical and other records (this could include your insurance claim file); (2) an interview with you and sometimes another person such as a family member or caregiver who knows you well, (especially if your disability impacts your ability to self-report); and (3) the administration of tests that measure both your mood and abilities.

The evaluation will typically begin with an interview and then proceed to testing.  The tests will be both written and oral, and vary in length and complexity.  Often the tests will be administered by a specially trained technician, or a psychometrist.  The typical evaluation takes between two to five hours to complete, but can stretch up to eight hours and/or be split into two sessions.  Conditions such as fatigue or motor impairments can slow down the process.

The results will generally be presented in a report that includes a summary of the tests conducted, a summary of your key medical and personal history, your current issues (i.e. the reason the neuropsychological exam was requested), the results of the testing, how these results compare to other people with your background, and a list of recommendations.  As explained previously, these recommendations can help indicate the need for additional treatment, suggest treatment options, and/or provide information on cognitive deficiencies and resulting physical and mental limitations.

The evaluation is designed to assess your knowledge, functioning, and skills at the time of the exam. Because of this, it is not the sort of test that you would “study” for, in the same sense that you would study for, say, an academic exam.  However, if you are going to be undergoing a neuropsychological exam, evaluators typically recommend that you:

  • Get a good night’s sleep
  • Put forth your best effort
  • Provide a list of all medications and take all medication as normally scheduled, unless instructed otherwise
  • Bring a friend or family member if you have trouble relating information about your history (for the interview portion of the examination)
  • Make sure the evaluator has access to your medical records
  • Do not consume alcohol or other illicit substances within the 24 hours prior to the evaluation
  • Notify the examiner of excessive fatigue, psychological distress, or frequent changes in your ability to move

Our next posts in this series will address the reliability of neuropsychological examinations and why your insurance company may ask for one.

Sources:

Atif B. Malike, MD; Chief Editor, et al., Neuropsychological Evaluation, Medscape, http://emedicine.medscape.com/article/317596-overview, updated May 18, 2017.

Neuropsychological Evaluation FAQ, University of North Carolina School of Medicine Department of Neurology, https://www.med.unc.edu/neurology/divisions/movement-disorders/npsycheval

Kathryn Wilder Schaaf, PhD, et al, Frequently Asked Questions About Neuropsychological Evaluation, Virginia Commonwealth University Department of Physical Medicine and Rehabilitation, https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwir3pKk__fUAhUBEmMKHenkDzsQFggoMAA&url=http%3A%2F%2Fwww.tbinrc.com%2FWebsites%2Ftbinrcnew%2Fimages%2FNeuropsych_FAQ.pdf&usg=AFQjCNG0Mv3o17ZrNmXuDN5ITUIh4fWYtA&cad=rja

What is a Neuropsychological Evaluation? – Part 1

We’ve talked before about how your insurance company may require you to undergo an independent medical examination (IME) by a physician of their choosing and how they may also ask for a Functional Capacity Evaluation (FCE).

Neuropsychological evaluations are another tool insurers utilize when investigating disability claims.  A neuropsychological evaluation is also something that a claimant filing a disability claim may choose to undergo independently, to provide additional proof of his or her disability.  In this series of posts, we will be talking about what a neuropsychological evaluation is, what to expect during an examination, and how an exam could affect your claim.

What is a Neuropsychological Evaluation?

Neuropsychology is the study of the relationship between the brain and behavior.  A neuropsychological evaluation is a method of testing where a neuropsychologist seeks to obtain data about a subject’s cognitive, behavioral, linguistic, motor, and executive functioning in order to identify changes that are, often, the result of a disease or injury.  The evaluation can lead to the diagnosis of a cognitive deficit or the confirmation of a diagnosis, as well as provide differential diagnoses.

Neuropsychological evaluations are most often associated with conditions that exhibit cognitive dysfunctions, such as

Conditions such as those enumerated above often have symptoms that vary person by person, and the amount of cognitive impairment can often not be fully assessed by other diagnostic tools such as an MRI, or a traditional psychological evaluation.

Neuropsychological tests are standardized tests that are given and scored in a similar manner each time they are used.  The tests are designed to evaluate the following:

  • Intellectual Functioning
  • Academic Achievement
  • Language Processing
  • Visuospatial Processing
  • Attention/Concentration
  • Verbal Learning and Memory
  • Executive Functions
  • Speed of Processing
  • Sensory-Perceptual Functions
  • Motor Speed and Strength
  • Motivation
  • Personality

There are many different accepted tests for each domain listed above.  Accordingly, an examiner will likely not perform every test, but rather select tests from each category that will best evaluate the particular question posed by the referrer.

The goal of these neuropsychological tests is to produce raw data.  The results are then evaluated by comparing test scores to healthy individuals of a similar background (age, education, gender, ethnic background, etc.) and to expected levels of cognitive functioning.  The data is then interpreted by the neuropsychologist, and perhaps other providers, to determine the strengths and weaknesses of the subject’s brain, provide suggestions for potential treatment options, set a standard for any future testing, evaluate a course of treatment, make recommendations on steps and modifications that can improve daily living, and evaluate whether a subject can return to work with or without modifications.

In our next post we will go look at what you can expect during a neurospychological evaluation.

Sources:

Atif B. Malike, MD; Chief Editor, et al., Neuropsychological Evaluation, Medscape, http://emedicine.medscape.com/article/317596-overview, updated May 18, 2017.

Neuropsychological Evaluation FAQ, University of North Carolina School of Medicine Department of Neurology, https://www.med.unc.edu/neurology/divisions/movement-disorders/npsycheval

Kathryn Wilder Schaaf, PhD, et al, Frequently Asked Questions About Neuropsychological Evaluation, Virginia Commonwealth University Department of Physical Medicine and Rehabilitation, https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwir3pKk__fUAhUBEmMKHenkDzsQFggoMAA&url=http%3A%2F%2Fwww.tbinrc.com%2FWebsites%2Ftbinrcnew%2Fimages%2FNeuropsych_FAQ.pdf&usg=AFQjCNG0Mv3o17ZrNmXuDN5ITUIh4fWYtA&cad=rja

Exertion Levels: What They Are, and Why They Matter

The Dictionary of Occupational Titles (DOT) contains definitions of various exertion levels that are used to place different jobs within categories based on the level of strength required to perform each job. You may have noticed these categories listed on claim forms, or referred to in functional capacity evaluation (FCE) reports or independent medical evaluations (IME) reports. In this post, we are going to look at what the various exertion levels are, and why they matter.

What Are the Exertion Levels?

The DOT lists five exertion levels—sedentary, light, medium, heavy, and very heavy. The DOT definitions for each exertion level are summarized below.

Sedentary Work (S)

Occasionally (i.e. up to 1/3 of the time) exerting up to 10 pounds of force and/or frequently (i.e. from 1/3 to 2/3 of the time) exerting a negligible amount of force to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve occasional walking or standing for brief periods of time.

Light Work (L)

Occasionally exerting up to 20 pounds of force, and/or frequently exerting up to 10 pounds of force, and/or constantly (i.e. 2/3 or more of the time) exerting a negligible amount of force to move objects. Requires walking or standing to a significant degree, requires sitting most of the time but also involves pushing and/or pulling of arm or leg controls, and/or requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible.

Medium Work (M)

Occasionally exerting 20 to 50 pounds of force occasionally, and/or frequently exerting 10 to 25 pounds of force, and/or constantly exerting greater than negligible up to 10 pounds of force to move objects.

Heavy Work (H)

Occasionally exerting 50 to 100 pounds of force, and/or frequently exerting 25 to 50 pounds of force, and/or constantly exerting 10 to 20 pounds of force to move objects.

Very Heavy Work (V)

Occasionally exerting in excess of 100 pounds of force, and/or frequently exerting more than 50 pounds of force, and/or constantly exerting more than 20 pounds of force to move objects.

Why Do They Matter?

Insurers usually rely on the DOT exertion levels in ERISA claims or cases involving “any occupation” policies. First, the insurer will seek to establish that the claimant can work at the highest level of capacity possible. Then, the insurer will claim that the claimant can return to work performing any job within that category, and any lower categories.

Conversely, if the case involves an “own occupation” policy, the insurer will seek to establish that the claimant’s occupation required the lowest level of capacity. The insurer will then assert that the claimant’s disability is not severe enough to prevent the claimant from returning to his or her old job.

In either case, if the insurer feels that it can demonstrate that a claimant is capable of returning to work, it will likely deny the claim for benefits, or terminate existing benefits.

References:

http://www.occupationalinfo.org/appendxc_1.html

Electronic Medical Records: What You Don’t Tell Your Doctor Might Hurt Your Disability Claim

Over the last ten years, there has been an increasing movement away from paper records and toward Electronic Medical Records (EMR).  This move has been accelerated by the federal government’s mandate that doctors who treat Medicare and Medicaid patients must have adopted and implemented EMR systems as of January 1, 2014.

There are many benefits to using EMR.  They can facilitate patient care between referring doctors, improve data tracking over time, increase efficiency and reduce errors.  However, EMR systems have drawbacks when they are used for purposes never intended, such as to document a disability claim.

Many EMR systems allow the doctor to input his findings for every major system in the human body, such as the cardiovascular, musculoskeletal, gastrointestinal, neurological and psychiatric systems.  However, if the doctor does not put in something regarding one of the symptoms, the default setting on the EMR will report the system as being “within normal limits” or that the patient has “no complaints.”  The concern with this from a disability perspective occurs when a patient sees his doctor for a condition unrelated to his disability.

For example, a patient with a history of degenerative disc disease could visit his doctor for an unrelated infection or illness.  Since the doctor is conducting only a limited examination for purposes of treating the presenting illness, he may not input any information related to the patient’s disabling condition.  The EMR will then generate an inaccurate record stating that the patient’s musculoskeletal system and neurological system are within normal limits.

Disability insurance carriers can then use these default settings to their own advantage to raise questions about the severity of the claimed disability, justify an independent medical examination or functional capacity evaluation, or support a claim termination.  For patients who are receiving disability benefits, it is therefore important to know what their medical records look like and to effectively communicate with their physicians to ensure that their conditions and symptoms are accurately recorded on each visit.

How Functional Capacity Evaluations Impact Your Disability Insurance Claim

Our last post discussed what to expect during a functional capacity evaluation (“FCE”), as well as the intended purpose of an FCE.  Though FCEs can be a useful tool for measuring your abilities, FCEs do not always provide results that are truly indicative of your ability to do your job on a regular, consistent basis.  Many courts have recognized the weaknesses and limitations of FCEs in the disability insurance claim context.

Weaknesses and Limitations of FCEs

There are approximately 10 different types of FCEs, each with its own program, measurement methods, and possible evaluative outcomes.  Because FCEs can be influenced by many factors, such as physical ability, beliefs, and perceptions, FCEs need to “be interpreted within the subject’s broad personal and environmental context.”[1] Thus, the FCE “process and its administration are only as good as the examiner.”[2]

Disability insurers often stop paying benefits based on FCE results, even when you can’t actually meet the demands of your former job duties on a consistent basis.  This is due to an inherent limitation of FCE testing: the FCE can only measure your capacity to do a certain task for a limited amount of time on a certain day.  For instance, you may be able to push and pull ten pounds for a few minutes during the FCE, but that doesn’t mean you can do the same task all day, every day.

Another important limitation of FCE testing is how effort is measured.  The FCE examiner normally monitors the subject’s heart rate to determine if he or she is putting forth full effort.  If your heart rate isn’t high enough, the examiner will say you didn’t try your hardest, so you can probably do more than you demonstrated during the testing.  However, there are factors that affect your effort level that can’t be measured by your heart rate alone. For example, heart rate monitoring doesn’t measure the impact of migraine headaches, kidney failure, or other non-exertional limitations (such as interference with attention and concentration due to pain and fatigue).

Continue reading How Functional Capacity Evaluations Impact Your Disability Insurance Claim

What Is a Functional Capacity Evaluation?

After filing a disability insurance claim, your insurance company may ask you to undergo a Functional Capacity Evaluation, or FCE.  The insurer tells you where and when to show up, but you likely have little idea what to expect when you arrive.  What is an FCE, what is its purpose, and how will it affect your claim?

What Is an FCE?

FCEs are formal examinations performed by occupational therapists (OTs) or physical therapists (PTs), not physicians.  The purpose of the FCE, according to your insurer, is to evaluate your ability to perform the substantial and material duties of your occupation.

What Can You Expect at the FCE?

FCEs usually last between four to six hours, but depending on the tests your insurer has requested, they could be longer, taking place over two consecutive days.

Continue reading What Is a Functional Capacity Evaluation?

Protecting Yourself in the IME Process: Reviewing the Policy

In this series, we are outlining some tips for claimants facing an Independent Medical Examination (“IME”).  Yesterday, we wrote about getting an attorney involved.  Today, we’ll explain another important step:

Make sure the exam is required by the policy.  This is another step where it is beneficial to have an attorney involved to review your policy.  Most disability insurance policies do have a provision that allows the company to have you submit to an Independent Medical Examination or Physical Examination.  However, sometimes those provisions aren’t totally clear on exactly what types of examinations are allowed.

For instance, here is a typical policy provision that your insurer might cite to tell you that you have to undergo an IME:

At our expense, we can have a physician of our choice examine you as often as reasonably required while your claim is continuous.

This provision states that the examination should be conducted by a “physician.”  Do you have to submit to a Functional Capacity Evaluation with a physical therapist?  The provision also states the examination should be “reasonably required.”  Has that qualification been met?

Here is another typical provision:

We shall have the right to have you medically examined at our expense when and as often as we may reasonably require while you claim to be disabled under this policy.

This provision says that you have the right to be “medically examined.”  Does that mean you can only be examined by a medical doctor?  Do you have to undergo a neuropsychological evaluation with a Ph.D.?  Again, has the qualification that the examination be “reasonably required” been met?

These are the kinds of questions you may want to get answered before you agree to the exam.

In the next post, we’ll talk about the IME intake forms.