Protecting Yourself in the IME Process
As we have discussed before, disability insurance claimants are often asked to submit to “independent” medical examinations (“IME”) with a doctor chosen by the insurance company.
IMEs are a source of anxiety for many insureds, especially because they are often a first step towards termination of a disability claim. Fortunately, there are some steps you can take to help ensure that you are treated fairly.
Over the next few days, we will outline some general tips on dealing with IMEs. Keep in mind that these tips are no substitute for the advice of a disability insurance lawyer who knows the specifics of your situation. Hence, today’s tip:
Get your attorney involved. If you don’t have a disability insurance lawyer to help you with your claim, now is a good time to seek some advice. Oftentimes, insurance companies use IMEs to try to show that you aren’t entitled to disability benefits anymore. A lawyer can help protect your rights during the IME process by, among other things, finding out what the disability policy requires (and doesn’t require) and discussing those requirements with your insurer. If you aren’t sure how to find the right lawyer, consider our Questions to Ask When Choosing a Disability Insurance Attorney.
Disability Claim Investigation:
What Can My Insurer Do In Arizona?
What your disability insurance company can do when it is investigating an Arizona claim for disability benefits largely depends on your specific circumstances and the language in your policy. However, there are some common tactics that Arizona courts will often allow – and some they will not.
What the disability insurance company can do
- Audit your tax returns and billing records
- Review your medical files
- Use a private investigator to conduct video and photograph surveillance
- Look at your public Facebook profile and pictures
- Follow you on Twitter
- Order an Independent Medical Exam
- Have an insurance company doctor opine about your disability
- Ask for a Functional Capacity Evaluation
- Contact your treating physician
- Schedule face-to-face interviews with you
- Interview your family, friends, co-workers and employees
- Demand precise quantifications of your time spent in every professional activity pre- and post-disability
- Pay your claim under a reservation of rights
What the disability insurance company cannot do
- Impose requirements on you that are not in your policy
- Attempt to influence the opinions of independent medical examiners
- Misrepresent policy provisions
- Conduct abusive interviews
- Unfairly delay a decision on your claim
- Fail to conduct a timely, adequate investigation of your disability claim
- Destroy key documents
- Lie about actions taken on a claim
- Place their financial interests ahead of your contractual rights
- Force you to litigate by offering an unreasonably low lump-sum buyout
When it comes to claims investigation, disability insurance companies often skirt the limits of what they can legally do. If you think your insurer might be acting in bad faith, contact an experienced Arizona disability insurance attorney to protect your disability benefits.
Senate Committee Concerned Over
Disability Insurers’ Unfair Practices
The Senate Finance Committee recently met to discuss laws surrounding private disability insurance. Members of the Committee expressed concern over current federal law, which gives private disability insurers substantial flexibility to engage in questionable practices. The Committee Chairman, for example, commented about the conflict of interests that hired physicians face when an performing “independent” medical examination (IME) on claimants:
Many of these doctors are employed either by the insurance company or by companies that do a lot of business with the insurance company. These arrangements make it far too easy for the doctors to deny claims, terminate claims, or reject appeals.
Committee members were also concerned about discretionary clauses that private disability insurance companies include in their disability insurance plans. These clauses give the disability insurance company discretion to review disability benefits determinations. They also enable disability insurance companies to avoid certain challenges to disability benefits decisions.
Disability insurance companies have financial incentive to deny disability insurance claims. As the discussion from the Committee meeting demonstrates, current holes in the law may actually provide insurance companies with means to engage in unfair practices for their benefit. Before filing a disability benefits claim, consider consulting with an attorney first. It is important to know your rights and to have an experienced professional guide you through this process.
To read more about the Senate Finance Committee Meeting, click here.
The 10 Biggest Legal Mistakes Physicians Make
When Filing a Disability Claim (Mistake #1)
If you are a medical or dental professional and are thinking that you may need to file a claim under your disability policy, you may be wondering “Do I need to hire an attorney to file a disability claim?”
Given the voluminous, complex language of modern policies and the amount of money at stake, failing to consult with a lawyer is one of the biggest mistakes professionals make when filing a disability claim. An experienced disability attorney can explain the significance of key policy terms, and work with you to present the best claim possible while avoiding the pitfalls we have identified in our previous posts on this topic.
Ed Comitz’s article, “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), discusses ten of the most significant mistakes to avoid. The excerpt below explains the importance of consulting with an attorney before filing a long-term disability claim:
MISTAKE NO. 1: Failing to Consult With a Disability Insurance Lawyer
Physicians who are considering filing a claim for disability insurance benefits are advised to meet with an attorney experienced in the area before submitting a claim for payment. Disability provisions vary greatly in the language used, and coverage is often circumscribed and restricted by qualifying words and phrases. Accordingly, each insurance policy must be individually reviewed to determine whether a particular claim is covered and, if so, how that claim is best presented to ensure payment.
Action Step: Physicians should make a coordinated effort with the assistance of an attorney when interpreting their policy, presenting their claim, and providing subsequent information to their carrier.
Insurers have laid plenty of traps throughout the claims process. They will use private investigators, video surveillance, social media platforms, and similar tactics to harvest information and set up your claim for denial or termination. To learn more about these tactics and other mistakes to avoid, click here.
The 10 Biggest Legal Mistakes Physicians Make When Filing a Disability Claim (Mistake #2)
Any medical or dental professional considering filing a claim or weighing long-term disability insurance policy options should be familiar with two key policy terms: “total disability” and “occupation.”
Misinterpreting the definitions of “total disability” and “occupation” and/or falling prey to other common pitfalls can lead to having your claim denied or your benefits terminated.
Ed Comitz’s article “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), details ten of the most significant mistakes to avoid. The excerpt below explains the importance of understanding these crucial definitions in your policy:
MISTAKE NO. 2: Misunderstanding the Definitions of “Disability” and “Occupation”
Because there is no such thing as a “standard” disability insurance policy, the definitions of “disability” can significantly vary. Most physicians purchase “own-occupation” policies, which provide compensation following a disability that prevents the insured from performing the particular duties of his or her occupation. Thus, the insured may be entitled to benefits even if he or she could in fact perform work of a different nature. The central issue in many cases is the definition of “total disability,” which could variously mean that the insured cannot perform “all” or “every” duty of his or her occupation, or the “substantial and material duties” of his or her occupation.
Similarly, the term “occupation” may be specifically defined in the policy (e.g., “invasive cardiologist”) or may refer to the insured’s occupation immediately prior to the time that disability benefits are sought. In the latter situation, if the physician reduces his or her hours in the months preceding claim filing, the insurer may consider his or her occupation to be part-time rather than full-time. Similarly, the term “occupation” may be comprised not only of the duties of a physician’s specialty, but also of significant travel time, teaching engagements, or other areas in which the physician spends time or draws revenue. For example, “occupation” may be defined as “internist/professor/business owner,” in which case the physician may not be “totally disabled” if he or she can still teach or perform management functions.
Action Step: Physicians should read and fully understand their policy terms before filing a claim for benefits.
Even if you read how these terms are defined in your own policy, you may not realize the significance of the definitions if you do not have a full understanding of the claims process and/or you have never seen any other policies for comparison as a frame of reference. Being familiar with the several variations of “own occupation” policies being sold by insurers can help you determine whether you have a true own occupation policy.
To learn more about some of the tactics insurers use to deny claims and other mistakes to avoid, click here.
The 10 Biggest Legal Mistakes Physicians Make
When Filing a Disability Claim (Mistake #3)
When you file a claim, at some point you will have phone calls with the insurance company regarding your claim. Oftentimes these conversations will be recorded and incorporated into the insurance company’s claim file, but you likely will not receive a copy of the recording unless your claim is denied and you end up filing a lawsuit challenging the denial. And even if the conversation is not recorded, it likely that, following your call, the analyst will be making a note in the claim file summarizing what was said in the conversation.
Because of this, it’s important that you do the same, to ensure there is a complete and accurate record of your interactions with the insurance company. Keeping records of what was said in these phone calls and evading other common pitfalls can help protect your claim from denial and your benefits from termination.
Ed Comitz’s article “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), details ten of the most significant mistakes to avoid. The excerpt below explains the importance of establishing a paper trail with your insurer:
MISTAKE NO. 3: Inadequate Documentation
When submitting a claim and speaking with their carrier, it is important that physicians take notes to assist them in remembering what was said in the event that their claim is denied. They should keep notes of all telephone conversations (including the date and time of the call, and what was said) and identify the person with whom they were speaking. Every conversation with the carrier should be confirmed in a letter sent by certified mail so that there are no misunderstandings. The “paper trail” may later be used as evidence to establish unreasonable treatment during the claim administration process.
Action Step: Starting with their first telephone call to their insurer, physicians should document in detail their conversations and meetings, and confirm everything in writing, sent by certified mail.
While you may have jotted down the occasional note when speaking with your disability insurer, you should now have a greater appreciation for the importance of establishing a record of what your insurer says and how they treat you. Detailed notes of conversations with your insurer can help shield valid claims from wrongful denial and even help prove bad faith conduct.
To learn more about some of the tactics insurers use to deny claims and other mistakes to avoid, click here.
The 10 Biggest Legal Mistakes Physicians Make
When Filing a Disability Claim (Mistake #4)
As part of your long-term disability insurance claim, your insurer may require you to attend an independent medical examination (IME), ostensibly to assess the validity of your filing. Many physicians, dentists, and other professionals (understandably) feel anxious and concerned about attending an IME set up by their insurer.
Ed Comitz’s article “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), details ten of the most significant mistakes to avoid. The excerpt below notes policy language to watch for and covers several helpful steps to consider before, during, and after your IME:
MISTAKE NO. 4: Blindly Attending an Independent Medical Exam
After submitting their claim, physicians may be asked to submit to an “independent” medical examination by someone chosen and paid for by their insurer. They may also be asked to undergo exams by someone other than a physician. Before submitting to an independent medical exam or any other exam or evaluation, physicians must first ensure that their carrier has a right to conduct the exam per the policy language. For example, a neuropsychological exam is conducted over several days by a psychologist, not a physician, and insurers often use the subjective findings from such an exam to deny benefits. If the policy requires submitting only to “medical exams” or exams “conducted by a physician,” there is certainly an argument that a physician need not submit to neuropsychological testing. Further, physicians may wish to be accompanied by an attorney or other legal or medical representatives who can monitor the independent medical exam. Other considerations include receiving the examiner’s curriculum vitae in advance; limiting the scope of the exam to ensure that no diagnostic test that is painful, protracted, or intrusive will be performed; having the exam videotaped or audiotaped; and receiving a copy of all notes and materials generated.
Action Step: Because the “independent” medical exam is a tool used for denying benefits where possible, physicians should work with an attorney to ensure that their rights are protected during this process.
Reviewing your policy’s requirements and preparing to attend an independent medical examination can make the process less stressful and protect valid claims from wrongful denial.
An IME is often just one part of your insurer’s broader investigation of your claim. To learn more about other common pitfalls to avoid, click here.
