Why Does My Insurer Want to
Conduct a Field Interview?
At some point after you’ve filed a disability insurance claim, your carrier may contact you to arrange a field interview. Also called a “field visit,” a field interview is when a disability insurer hires a representative to come meet with you face-to-face to talk about your benefit claim. Most times, the company will ask that you meet the field representative at your own home or office.
Your claims analyst will probably tell you that the field interview is just a way to get to know you better, or to help the company gain a better understanding of your disability claim. What the claims analyst won’t tell you are the real reasons why insurance companies put so much time and effort into planning in-person field interviews, such as:
- To take your picture so that a private investigator will recognize you during surveillance.
- To find out what your house and/or office looks like to further aid in surveillance.
- To look inside your house and see if you’ve been doing a lot of housework, paperwork, cooking for yourself, etc., all of which (according to the insurance company) can mean you’re able to work in your own occupation.
- To see if you look like you’re in pain, if you can sit down for a long period of time, or if you can walk without any gait abnormalities.
- To see if you look like you might have current monthly income from sources other than your occupation (i.e., if you have a nice car, a big house, a boat, etc.).
- To drop in and try to interview your spouse, former business partners, office manager, or neighbors.
- To try and get you to relax and open up, or to catch you off guard so that you give information the company can use against you.
In our next post, we’ll discuss what you can expect during the field interview itself.
Why Won’t My Doctor Help
With My Disability Insurance Claim?
We frequently discuss how important it is for your treating doctor to support your disability insurance claim. Oftentimes, though, doctors are reluctant to help with the process. Understanding why your provider is hesitant to get involved can better equip you to enlist his or her support.
In our experience, these are the most common reasons why treatment providers decline to assist with disability insurance claims:
They don’t have time. Doctors have extremely busy schedules. Often, they’re concerned that they simply don’t have enough time to properly complete all of the insurance company’s required forms or to answer questions from your claims adjuster.
They are worried about the insurance company harassing them. Many healthcare providers know how complex and combative disability insurance claims can be. Sometimes, providers don’t want to get involved with a claim at all, because they’ve heard of (or experienced) claims personnel harassing treating doctors. This can be a legitimate concern, as left unchecked, insurance companies will often bother treating doctors with repetitive requests for information, pushy phone calls, or by second-guessing the doctors’ treatment plan.
They are worried about doing something to hurt your claim. On the other hand, many providers aren’t familiar with the private disability insurance claims process at all. This sometimes makes providers hesitant to complete Attending Physician’s Statements or to discuss your claim with an adjuster for fear that they will inadvertently say something that prejudices you.
They don’t know the definition of disability in your policy. Not every treatment provider is familiar with the type of own-occupation policy that many physicians, dentists, and other professionals purchase. When some providers hear the word “disability,” they think of a state of total helplessness, or of the much more stringent Social Security definition of “disability.” If a provider doesn’t know that your policy deems you “disabled” if your condition prevents you from performing the duties of your own job, he or she might think you don’t qualify for disability benefits.
Continue reading “Why Won’t My Doctor Help
With My Disability Insurance Claim?”
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.
Beware the “Offset”
Insureds may think that if their disability claim is approved and the insurer begins paying disability benefits, they have won the battle. In reality, however, even the insurer’s complete admission that the insured is disabled within the terms of the policy does not mean that the insurer will pay the full monthly benefit listed in the policy. Most of us think of disability insurance as providing a stream of income to replace lost salary, but few understand that these policies often contain language effectively cutting off other benefits to which the insured would otherwise be entitled.
Disability insurance policies, especially long-term disability policies, frequently contain “offset” provisions, which offset other benefits against the insurer’s monthly payments. Common offsets include benefits which the insured receives from Social Security disability or retirement, unemployment compensation, worker’s compensation, no-fault auto insurance, sick leave, severance pay, and others. The net effect of these offsets is that should the insured receive a benefit from another source, the disability insurance company will reduce its monthly payment by the same amount.
How Can I Keep My Disability Insurance Company From Contacting My Doctors Without My Consent?
In our recent post, “Should Disability Insurance Companies Be Deciding What Kind of Care You Receive?” we explained that insurance companies will often contact your treatment providers directly without your consent, ambushing them with medical studies and demanding answers to a plethora of questions about your medical treatment in an effort to undermine your disability claim. In many instances, insurance companies will refuse to produce the medical reports their in-house doctors wrote about you, but still expect full access to your treatment providers and their reports.
If this happens to you, you may (justifiably) feel like the insurance company is going behind your back and unfairly manipulating the disability claims process. Your treatment providers may become upset because the insurance company is harassing them to respond to detailed questions without adequate time to understand the questions and/or provide thorough answers. You may even notice your doctors acting differently towards you after speaking with the insurance company. For example, your doctor might begin to avoid you when you ask him or her to provide you with documentation to support your disability claim.
How can you protect your treatment providers from being ambushed by insurance companies and protect your claim from being manipulated?
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 disability 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 disability 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?”
How Long Do I Have to Formally File My Claim?
You have finally come to the realization that working through the pain and limitations of your disability is no longer in your best interests. Continuing to work is not an option for you, so you have decided to make a long term disability insurance claim. How long do you have to file your claim? Does it have to be on the day that you become disabled, or can it happen a couple months down the road? The answer to that question is: it depends.
Insurance companies will try and exploit every option available to deny a claim for disability insurance benefits. One method they utilize is to put strict requirements on how and when an insured must give notice to the company of their disability and what that notice must contain.
The first place to start looking to determine your insurance company’s requirements is the insurance policy itself. Look through the policy index or headings for a section similar to “Notice of Claim.” This section lets you know how much time is available to file a disability claim with the company. Continue reading “How Long Do I Have to Formally File My Claim?”
ABC News Investigates
CIGNA’s Disability Claims Handling Practices
UPDATE: Since this story was originally posted in 2008, the insurance regulators of Maine and Massachusetts initiated targeted market conduct examinations of CIGNA’s disability claims handling practices. The concerns raised by Maine and Massachusetts prompted the insurance commissioners of Connecticut and Pennsylvania to also open market conduct examinations and for the California Insurance Commissioner to reopen his previous examination of CIGNA. In 2013, the examinations resulted in fines against the CIGNA companies, corrective actions being required in its handling of disability claims, and for CIGNA to reevaluate certain claims that were denied or terminated. Information on the CIGNA Multi-State Regulatory Settlement Agreement can be found here.
ABC News/Good Morning America‘s investigation by Chris Cuomo into CIGNA disability claim denials has uncovered some disturbing stories. In the video above, claimants describe some of the hardships they have been forced to endure due to denials of their claims or unreasonable delays in having their claims paid.
One breast cancer survivor, who eventually was paid on her claim with the assistance of a disability insurance attorney, describes her two-year ordeal with CIGNA as a “daily, eight-hour job just to fulfill the information that CIGNA was requesting.” The tactic of wearing down a disabled claimant with repeated requests for documentation that has already been provided multiple times — thereby deliberately delaying payment of the claim — is called “slow walking” by some in the industry. While CIGNA denies engaging in this practice, many claimants who are already emotionally and physically vulnerable due to their disability will eventually quit pursuing benefits to which they are entitled in this battle of attrition that is widespread in the disability insurance industry. In this situation, it is often necessary for a claimant to retain the services of an attorney, not only to take on legal issues with the insurance company but also to shoulder the burden of the excessive and repetitive requests for documentation.
Other claimants in Chris Cuomo’s GMA piece describe (a) three years of fighting CIGNA for their benefits, all the while sinking deeply into debt and losing everything; (b) being caught between a rock and a hard place when told by an employer that he could not return to work due to his disability, but simultaneously having CIGNA deny disability benefits; (c) purchasing insurance to protect herself and her family, only to have her business destroyed, savings depleted and fighting to keep her family home when benefits were denied or delayed.
Another of the claimants profiled, Ursula Guidry, a young wife and mother with advanced breast cancer, initially had her benefits paid by CIGNA, but after awhile, they terminated her benefits and told her she could return to work full-time. Eventually CIGNA settled the claim with her. She passed away three months later. As her husband says, it is tragic that her last year on earth was spent being in a panic over financial issues and fighting an unethical insurance company instead of enjoying as much time as possible with her husband and children.
CIGNA did not respond to GMA re any of the specific claimants profiled, but their Chief Medical Officer stated they pay 90% of disability claims filed and that the majority of their customers are satisfied.
How to Tell if an IME Doctor is Really Independent
At some point during many disability insurance claims, the claimant is compelled to undergo a so-called Independent Medical Examination, or “IME”. The purpose of the IME is supposedly to have an uninterested, unbiased doctor examine you to verify whether your condition truly makes you totally disabled under your disability insurance policy’s terms. However, IMEs are often used as yet another tool for the insurance company to attempt to deny or terminate your claim for disability benefits.
Though IMEs are labeled “independent”, the doctors performing them are almost always selected and paid by the insurance company. Further, many of the IME providers are used over and over again by the same companies. IME doctors that depend on the insurance industry for their livelihood have a strong incentive to give the insurance companies results they desire–medical opinions that support the denial or termination of your disability claim.
Continue reading “How to Tell if an IME Doctor is Really Independent”
Can My Disability Insurance Company Contact My Employer?
We previously posted about the breadth of authorization forms that disability insurers request you sign at the beginning of your claim for disability insurance benefits. These forms allow your insurance company not only to obtain medical records and other relevant information, but also to contact your employer to discuss your specific job duties, among other things.
This can be unsettling as you may not want your employer to know about your medical condition, or you may fear what your employer might say that could jeopardize your disability claim. Unfortunately, there is little that you can do to stop the interview from occurring, but you can prepare yourself and your employer beforehand.
Most policies require that, in order to be considered “Totally Disabled,” you must be unable to perform the material and substantial duties of your occupation, and be under the regular care of a physician. Accordingly, your insurance company needs to ascertain your important occupational duties.
If you can still perform some of your important occupational duties, though not all of them, you will not be considered “Totally Disabled” under most policies. It is important, therefore, to anticipate that your insurer will contact your employer so that you can ensure that only accurate and relevant information is communicated.
There is a critical difference between important occupational duties, and those that are merely incidental. Duties that encompass only a small percentage of your time are incidental or peripheral duties and not part of your regular profession. It is therefore improper for your insurance company to consider these duties when determining your eligibility for disability benefits.
For example, a licensed dentist who works 90% of the time treating patients and 10% of the time on administrative duties is regularly engaged in chair dentistry for purposes of an own- occupation disability insurance claim. Administrative work such as overseeing office staff, paying bills or attending continuing education classes are merely incidental to his material and substantial duties as a full-time dentist.
By focusing on insignificant duties, and getting your employer to sign off on those duties as important parts of your regular occupation, your insurance company will have made it much more difficult for you to collect your rightful benefits. While this is an unscrupulous practice, it often occurs and produces an unfair result. Considering each and every incidental duty and allowing a finding that you are Totally Disabled only if you are unable to perform each and every one of those duties is a nitpicking approach that would equate Total Disability with utter helplessness. Obviously, that is not the type of coverage that you purchased, nor what had been marketed to you at the point of sale.
To ensure that your employer does not provide misinformation to your insurance company during the interview, here are some tips:
Prepare an Occupational Description: Prepare an occupational description listing your important duties and have your employer sign off on it. Then provide the occupational description to your insurance company at the beginning of your claim. By reviewing this document with your employer, it will be less likely that your insurance company will be able to focus on the irrelevant, incidental duties of your job.
Explain How Your Policy Works to Your Employer: Let your employer know that you have an occupation-specific policy that entitles you to benefits if you cannot perform the important duties of your job. Further explain that your occupational description is intended to outline your important duties, and other duties you may perform are merely incidental. This way, you are focusing your employer on what’s relevant and preparing him or her for the interview.
Being prepared and vigilant at the beginning of your claim increases the likelihood that you will be paid the disability insurance benefits that you deserve.
Authorization Forms: What Information Are You Releasing to Your Disability Insurer?
Whenever you file a claim for benefits with a disability insurance company, you will be asked to complete numerous forms. One of these forms is always a HIPAA-compliant Authorization. This form is titled differently depending on the insurer in question, for instance:
-
- Authorization to Obtain Information (Guardian/Berkshire)
- Authorization for Release and Disclosure of Health Related Information (Sun Life)
- Authorization (MetLife, Unum, Northwestern Mutual)
- Authorization for Release of Personal Health and Other Information (Principal)
- Authorization for Release of Personal Health-Related Information (MassMutual)
Claimants often sign the Authorization with little more than a quick glance, unaware of the broad power they are giving their insurer to investigate nearly every aspect of their lives. This may seem like an exaggeration, but take a look at this paragraph from an actual Authorization form required by one of the leading disability insurers for doctors and dentists.
Many claimants think that the Authorization simply allows the insurer to collect medical records. However, this Authorization, like those we typically see from other disability insurers, lets the company request all kinds of documents from all kinds of people and agencies. It also allows various company representatives to speak directly with numerous people in a claimant’s life. Let’s examine what you would authorize by agreeing to this one paragraph:
Disability Insurance Q&A: How Should Doctors Approach Their Treating Physicians About a Disability Claim?
Question: How should doctors approach their treating physicians about a disability claim?
Answer: Your treating physician’s support can often be critical to getting your claim approved. A hurried, uninterested physician may not have time to devote to your claim. In addition, fully discussing your condition with a professional, compassionate treating physician will help ensure supportive medical records. When to discuss your potential claim with a physician is an important timing issue. Also, when the time comes to speak to the treating physician about the claim, a disabled dentist or doctor should ensure that the treating physician understands the definition of “disability” under the insurance policy, so that he or she can accurately opine as to the inability of the doctor or dentist to work.
Some of our previous blog posts on this important issue are available here and here.
Disability Insurance Q&A: Why Do So Many Doctors’ Claims Get Denied, and How Can a Law Firm Help?
Question: Why do many doctors’ disability claims get denied, and how can a law firm help?
Answer: Doctors’ and dentists’ disability claims can be expensive for insurance companies to accept. The troubled economy and the rising number of disability claims filed by healthcare professionals have led to financial hardship. This strain on resources creates an incentive for insurance companies to deny medical professionals’ claims. Thus, many insurers closely scrutinize the terms of doctors’ and dentists’ policies in order to find ways to deny disability insurance benefits, as the long-term financial benefit to the insurance company is significant.
Our firm has years of experience in cases in which disability benefits have been rescinded based on alleged misrepresentation or non-disclosure in the original policy application. We also have a strong history of prosecuting cases in which benefits have been denied based on the insurance company’s insistence that a dentist’s or doctor’s “subjective claim” doesn’t provide objective evidence of disability.
Further information on our law firm’s services and what you can expect when filing a disability claim is available on our website at this link.
Disability Insurance Q&A: What Does Your Firm Do To Help Doctors File a Successful Claim for Disability Insurance Benefits?
Question: What does your law firm do to help doctors file a successful claim for disability insurance benefits?
Answer: From the beginning of the process, we help doctors, dentists and other professionals by analyzing complex claims applications and disability insurance policies and identifying potential coverage issues. We have particular skill in documenting claims, completing claim forms, and communicating with treating physicians. Once the claims process begins, we fiercely protect our clients against unreasonable delays and abuse by the disability insurer. We also provide knowledgeable advice and practical guidelines on how to handle an independent medical examination or other testing that may be required by the disability insurance carrier.
Further information about what we do and what to expect is available on our website at this link.
Disability Insurance Q&A: When Should I Contact An Attorney About My Claim?
Question: When should I contact an attorney about my claim?
Answer: Doctors and dentists who are considering filing a claim for disability insurance benefits should meet with an attorney experienced in the area well before submitting a claim. Each disability policy has different, complex language that insurance companies may manipulate to circumscribe and restrict coverage. A physician or dentist should make a coordinated effort with an attorney’s assistance to determine whether a particular claim is covered, and if so, how that claim is best presented to ensure payment.
Coming soon, we will be distributing a monthly e-mail newsletter. The newsletter will contain information not included on this blog, such as:
- Detailed tips for filing disability insurance claims with various carriers;
- Examples of best practices vs. worst practices when interacting with your insurer;
- Updates on recent disability cases relevant to your claim or potential claim;
- Specific answers to common questions, which newsletter recipients can submit anonymously; and
- Information on lectures and classes you can attend to hear the firm’s attorneys speak about choosing disability insurance policies and filing claims.
If you are interested in subscribing (at no cost, of course), please sign up here:
Disability Insurance Newsletter
Your name is not required. Please rest assured that we will not use or distribute your e-mail address for any other reason.
Should Your Disability Insurer Still Require Medical Treatment?
Almost every disability insurance policy issued today requires that you are under the regular care of a doctor in order to be eligible for total disability benefits. However, for permanent medical conditions, sometimes additional treatment just isn’t necessary. For instance, if you undergo a spinal fusion, no amount of treatment is ever going to restore you to exactly how you were before. In addition, people with disabilities are often in a financially vulnerable position, and paying for unnecessary medical treatment can cause further strain.
The people that write and sell disability insurance policies understand this, so they often include an additional benefit in the policies: a waiver of the medical care requirement when treatment is no longer needed. This reasonable provision helps sell policies.
Unfortunately, once a claim is made, the companies are often unwilling to actually provide the benefit. What many insureds may not realize is that the language of these waiver provisions is designed to give the company wide latitude in determining whether or not to provide the benefit.
Continue reading “Should Your Disability Insurer Still Require Medical Treatment?”
Protecting Yourself in the IME Process: Get a Copy
This post is the last in our series on tips for undergoing disability insurance Independent Medical Examinations (“IME”). Today’s topic is a step to take after the examination is over:
Get a copy. After the exam, contact your insurer to ask for a copy of the IME report. Most IME doctors have a copy of their report to the disability insurer within two weeks. Your insurer may send a copy of the IME report to your own treating physician and ask for his or her comments on the exam. In that case, the company will require you to request the IME report directly from your own physician.
When you get the report, review it and compare it against your notes and/or recollection. If anything needs to be clarified, discuss it with your disability insurer or attorney. If you received the copy of the IME report from your own physician, talk about it with him or her. An inaccurate or misleading IME report can be dangerous to your claim for disability benefits, so it’s important to address any inconsistencies as best you can.
For more information on dealing with an IME, see our prior posts:
Protecting Yourself in the IME Process
Completing Intake Forms in Advance
Protecting Yourself in the IME Process: Bring a Friend
We have talked about involving a disability insurance attorney in the IME process, understanding what the insurance policy requires, completing intake forms, making lists, and taking notes. Today in our series about tips for Independent Medical Examinations:
Bring a friend. Taking notes is great, but having a witness present is best. That way, you can focus on participating in the examination, and your witness can focus on observing and taking notes. Moral support is an added benefit.
A friend, spouse or partner can be a good witness, especially if he or she is a medical professional. If you have a disability insurance attorney, he or she may also attend with you or send a representative from the law office.
Take note, however, that some insurance companies specifically state that witness are not allowed at IMEs. Normally, this alleged requirement is stated in the letter the insurer sends you to confirm the examination. If you have a disability insurance attorney involved, the attorney can review the letter, the policy and the law and determine whether or not a witness is allowed to attend.
Protecting Yourself in the IME Process: Make Lists and Take Notes
In our series of suggestions for handling an Independent Medical Examination (“IME”), we have already discussed getting a disability insurance attorney involved, knowing the disability policy requirements, and completing the intake forms. Here are today’s tips:
Make lists and bring them to the IME doctor. Don’t be afraid to bring information with you to help answer questions from the IME doctor. Some examples are a timeline of your symptoms—i.e., when they started, when they got worse, etc.—or a list of all your medications so you don’t accidentally forget one. If you have photos or videos showing certain injuries or symptom flare-ups, consider bringing those along as well.
Take notes. This will make sure that your recollection of the IME is recorded along with the doctor’s recollection. Your notetaking should start when you arrive at the IME provider’s office, as your time in the waiting room is often part of the final IME report.
For instance, IME doctors will often report something like, “The patient sat for half an hour before my exam completing the paperwork without any apparent discomfort.” If you take notes before the IME to memorialize how long you sat in the waiting room, if anyone was watching you fill out the paperwork, if you had to stand to stretch, etc., you will be able to show the insurance company whether the doctor’s statement is accurate.
If possible, take notes during the IME as well, so that you can remember exactly what testing was performed and what types of questions were asked.
When you leave the IME, take a few minutes to immediately jot down your impressions and any issues you think you need to follow up on with your disability insurer or attorney.
