At Dell & Schaefer, we’ve seen insurance companies give countless reasons to deny long term disability benefits. However, most disability benefit denials tend to fall into one of a few categories—and one of the biggest ones is the paper review and independent medical exam (IME). Learn more about what this review process entails and what your claim file will need to show in order to reduce the risk of denial.
Your Claim File Will Be Reviewed By the Disability Company’s In-House Staff
The disability insurance carrier will have their own nurse or in-house doctor (or a third-party company) review your medical records to determine if you’re disabled. This “paper review” can be frustrating and reveals one major double standard in disability claims evaluation—though the insurance company would never accept a disability claim if the claimant had never been physically examined by a doctor, it will often reject a claim based on its own paper review of your file. Unfortunately, the file review is a common process, so claimants must work within this process to obtain approval.
To get past this process, you’ll need to ensure that your claim is as complete, comprehensive, and unassailable as possible. Any omissions or inconsistencies in your medical records could give the insurance company the opening it needs to deny your claim.
You’ll Need to Do Some Research Before Agreeing to the Independent Medical Exam
If the insurance company isn’t satisfied with the information in your claim file, it may ask you to undergo an independent medical exam or evaluation. The IME involves a contract between the disability insurance carrier and a third-party vendor; this vendor will conduct a physical or cognitive evaluation to determine whether you continue to meet the definition of “disability” under your policy.
It’s important to do some research before agreeing to be seen by the doctor the insurance company has named. If you search this doctor and see that they don’t actually see their own patients—but instead, only do medical reviews—this can be a red flag that the doctor will be a hired gun for the insurance company. In these situations, you can request to be seen by another doctor who may be less likely to skew their review toward the insurance company.
Third-Party Examiners Have a Vested Interest in Denying Claims
Because the third-party examiner is hired by the insurance company, it will often have a vested interest in denying your claim. On the other hand, insurance companies may argue that your doctors have a vested interest in claim approval since they have a long-term relationship with you as their patient. Although some IMEs do come back in the client’s favor, it’s important to always approach this process with some skepticism, and don’t be afraid to request a new doctor or dispute the findings in the IME report.
Disputing the IME Report
Under the new ERISA laws, you’ll have the opportunity to reply to an unfavorable IME report before the insurance company makes a final decision on your claim. But because the standard for reversing a disability claim denial is whether the insurance company’s decision was “arbitrary and capricious,” it’s important to coordinate with your treating physicians to respond in full to everything in the report you disagree with. If your response is too short or doesn’t hit all the points it needs to, the insurance company can later argue that it gave you the opportunity to dispute its findings and you didn’t. This will make it harder to prove that their decision was arbitrary and capricious.
As you can see, handling the paper claim review and the IME can be crucial to obtaining approval of your claim for long term disability benefits. Having an attorney throughout this process can help ensure that your claim file is in order and there aren’t any loopholes the insurance carrier can use to deny your claim. At Dell & Schaefer, we’ve helped thousands of claimants secure their long term disability benefits, and we can help you too. To get started, just give us a call to set up your FREE consultation.