How Insurers Cherry-Pick Medical Records to Deny Claims
Oct. 6, 2022
According to the Council for Disability Awareness, about one in every four of today’s 20-year-olds will suffer a disabling condition before they retire and will face a period of three months or longer when they cannot work. The savvy among those entering the workforce will purchase a long-term disability (LTD) insurance policy sponsored by the company they work for.
Though those who purchase LTD policies expect the insurance company underwriting them to be “Johnny on the spot” when it comes to providing benefits during times of disability, the reality is that insurance companies are for-profit enterprises. Accordingly, they will do everything they can to reduce or eliminate their liability.
Though insurance companies are not required to submit data on LTD claims denials, if the rate is anything like that of the Social Security Administration (SSA) and its Social Security Disability Insurance Program (SSDI), the initial denial rate will be 50 percent or higher. One of the primary reasons cited for denial of private LTD policies is that the medical evidence doesn’t support the claim.
Submitting medical evidence to justify your claim of a disability seems like a reasonable requirement, but insurance companies have a habit of emphasizing medical evidence you submit that can be viewed as running counter to your claim, while ignoring evidence that supports your claim. This is a practice known as “cherry-picking.”
To carry out this cherry-picking, LTD insurers will often hire what they refer to as independent medical professionals to review the evidence you submit. Since these “independent” professionals are being paid by the parent insurer, however, the odds are that they will be looking for evidence that can be used to diminish or dispute your claim altogether.
If you find yourself in a situation where you have been judged disabled by your physician but turned down by your LTD insurer in or around San Francisco, or anywhere in California, contact The Law Office of Bennett M. Cohen, P.C.
We will fight for the benefits promised to you under the terms of your LTD policy. We are well aware of the tactics – including cherry-picking – employed by LTD insurers and can counter their findings by pointing out and reinforcing medical documentation that the insurer ignored or downplayed but which fully justifies an award of disability benefits.
What’s in Your Medical Records That Can Affect Your Claim?
The answer to this question could be, quite frankly, “anything” that the insurer can use to show that your physical or mental condition does not prevent you from working.
For example, the insurance adjusters and examiners may ignore MRI results that show a back condition that prevents a claimant from carrying out his or her normal warehouse duties, but will focus on another statement by the doctor that the claimant can sit for eight hours at a time. The insurer will then argue that the claimant can take on a sedentary, desk-based position and continue to work.
Many policies also contain exclusionary periods during which any disability that results from a pre-existing condition will not be covered. The insurer will certainly look to enforce this provision to the max.
The insurance adjusters and medical examiners, even after the end of the exclusionary period, can still try to argue that your current condition – suddenly deemed disabling – is just a continuation of your pre-existing condition symptoms and you are, therefore, capable of continuing to work. This is especially so if you failed to disclose the pre-existing condition when you applied for the policy.
All in all, when it comes to LTD policies, you need to check the wording carefully for how the underwriting insurance company treats pre-existing conditions and also scour the document for any loopholes or “out” mechanisms built into the policy.
Medical Records Include More Than Test Results and Physician Statements
Though your submitted medical records will no doubt include the results of any tests that have been conducted on you, along with a statement by your physician – or physicians – supporting your claim to be disabled and unable to work, the parent insurer will also be looking at how you follow through on your medical evaluation and recovery plan.
An LTD insurer will look askance – and limit or deny benefits – if you claim a disability and then skip doctor’s appointments or ignore your prescribed treatment regimen. The parent insurer will expect that, once you begin receiving your benefits, you will be undergoing continued evaluation and treatment – and submitting follow-up medical evidence, which should include MRIs, X-rays, blood test results, and other test results.
Of course, insurers have also been known to use surveillance to follow you around in public spaces to see if you really do display symptoms of your disability. This is just another method they often employ to cast doubt on the medical evidence submitted to support your claim.
Options If Your Claim Is Denied
If your policy was purchased at work, then it is covered by a law known as the Employee Retirement Income Security Act (ERISA), which sounds employee-friendly, but in truth, serves as a legal protective shield for LTD insurers. ERISA contains appeal procedures if you have been denied benefits, or saw them curtailed or eliminated, and you need to follow these procedures to the letter.
In the initial appeal stage, you are allowed to submit additional medical evidence and testimony by physicians and others, including vocational coaches and professionals, even friends, neighbors, and co-workers, describing your condition and its limitations. Once the LTD insurer issues a final denial, however, all evidence is sealed and nothing more can be submitted.
This means that, should the denial reach the stage of a lawsuit, the case will be heard by a federal judge who will be restricted under ERISA to examining only the documents and evidence submitted prior to the lawsuit. You will not be allowed to testify, nor will your physician. The LTD insurer hands over its file, and the judge rules accordingly.
Therefore, it is absolutely essential that, before a lawsuit ever becomes necessary, you submit the full range of possible medical evidence and supporting testimony. “Don’t leave a stone unturned,” as the saying goes, when it comes to compiling supporting evidence with which to inundate your LTD insurer.
Rely on Experienced Guidance Every Step of the Way
Even if you think your case for disability benefits is clearly evident from the medical evidence and doctor’s statement you submit, the insurance company will use every option it has to challenge the evidence and even cherry-pick those bits of evidence that may justify a denial of benefits.
Thus, from the very beginning of the claims process, you need to enlist the guidance and aid of an experienced disability attorney to assemble the most comprehensive package of evidence and testimony possible, and then to challenge any counter-assertions by the insurer by using the full range of supporting evidence.
If you’re in the San Francisco area of California, or really anywhere in the state, and you face an LTD claim denial or are being challenged in your claim, contact The Law Office of Bennett M. Cohen, P.C.
Better yet, reach out the moment you need to file for LTD benefits. The more comprehensive the package you submit in the beginning, the harder it is for the insurer to deny your claim, and the easier it is for you to challenge any grounds they find for denial.