What to Do When Your Disability Insurance Disagrees with Your Doctor?
If you’ve applied for long-term disability (LTD) benefits, chances are you are probably dealing with a case manager, your doctor(s), treatment regiments and everything in-between. Your doctor supports your medical leave, but the insurance company doesn’t agree with what your doctor is saying. Is your insurer claiming there is insufficient medical information on your file to support your disability? What does that mean and what can you do? In this blog, we discuss what to do when your disability insurance disagrees with your doctor, and potential options to consider if your insurer isn’t seeing eye-to-eye with your doctor.
What are long term disability benefits?
Long-term disability benefits are a monthly income benefit that is available through your employer’s group benefits policy. If an injury or illness prevents you from working, you may qualify for LTD benefits.
In submitting an application for LTD benefits, you’ll need three forms:
- Plan Member Statement (PMS), a form filled out by you;
- Plan Sponsor Statement (PSS), a form filled out by your employer; and
- Attending Physician Statement (APS), a form filled out by your doctor.
The Attending Physician Statement
In support of your LTD claim, the insurance company will require medical records. These are records available through your treating practitioners. Remember, your only required to provide records that are relevant to your claim for disability. For a simple example, if you’re off due to an ankle fracture, your dental records are likely not relevant to your claim.
Your doctor is responsible for filling out an Attending Physician Statement. This form outlines the primary and secondary diagnoses in relation to your condition. The form also asks for the doctor to comment on other treatment providers you are seeing (or are scheduled to see), prescribed medications and an anticipated time for recovery. If your anticipated recovery is not known, the doctor will indicate on the form.
Your Doctor vs. What Your Insurer Says
Case manager are not doctors. They work for the insurance company to adjudicate your claim. This means, taking your medical condition and records combined with the information on your claim to determine whether your meet the definition of disability as indicated in your policy.
LTD insurers have resources. This means if the case manager feels there is a gap in your claim, they have ways to fill it. They could fill it by conducting a functional telephone interview with you or by setting you up for an assessment. The type of assessor would depend on your condition. Case managers also have access to medical consultants who can do a paper review of your file to comment on your restrictions and limitations.
If your doctor says you are unable to work due to your illness or injury, but your case manager feels otherwise, they should utilize one or more of the aforementioned assessment tools to get a better understanding of your overall condition.
If you have delivered a medical note from your doctor supporting your inability to work and the case manager indicates it is inadequate, ask your case manager to submit a medical questionnaire to your doctor. This is a form that outlines specific questions from the case manager which should be used to help adjudicate your claim.
If your case manager does not feel a medical questionnaire is necessary, you can ask for clarification on where the medical note is lacking and request a more specific note from your doctor. If you are seeing more than one medical provider (such as a psychiatrist, social worker or physiotherapist), you have the option of submitting other medical documentation in support of your claim from other medical providers.
If you are still at an impasse with your case manager, chances are the insurer is looking to deny your claim.
LTD Claim Denied due to “Insufficient Medical Information”
Your insurer may deny your claim even if you’ve submitted support from your doctor, an abundance of medical records and have clearly told your insurer you’re incapable of working. Insurers commonly deny LTD claims indicating there is insufficient medical information on file to support a finding of total disability. In your denial letter, the case manager will cherry pick medical notes in support of your denial which aren’t representative of your overall condition. For example, if your doctor has noted a slight improvement in your condition, your insurer may exaggerate that specific note and use it to deny your claim.
If you are wondering what to do when your disability insurance disagrees with your doctor and denies your LTD claim. The answer may be that it’s time to get a disability lawyer involved. With a lawyer on your side, you’ll receive a voice to challenge the medical evidence the insurer has attempted to misconstrue. Not all denials are justified. If your insurer has wrongfully denied your claim due to insufficient medical information or for any reason, the disability lawyers at Whitten & Lublin can help you challenge the denial and take back control of your rights. We offer free consultations for short and long-term disability claims. Contact us online or call (416) 640 2667.
Author – Aman Chaggar