Disability Claims, A four part Article
Disability Insurance Claims – An
Inside View (part 3)
By Gerry Katz, MSPA, RHU, ALHC,
You should be aware of the
several Investigative Tools used by insurance carriers to help legitimize
disability insurance claims. These
I won’t go into great detail
about each of these tools but do want you to better understand their use in
evaluating the merits of a disability claim.
Attending Physician Statements are just
what they sound like. The physician
caring for a disabled client of yours will be asked to submit an initial APS
outlining the specific disability and its resulting limitations and
restrictions on the insured. He or she
will also be asked for specific dates of treatment, when the total or partial
disability began and when the physician feels your disabled client can or will
return to full-time or part-time work.
In addition to
many disabled insured’s not completing their initial claim application
properly, the APS is often incomplete, at times confusing to claim personnel
and in my experience, can be the cause for some disagreement between insured
and insurance company, regarding the degree of disability. It is important for the treating physician
to understand the nature of disability, not merely be able to describe symptoms
and treatment! He or she must also
understand what your disabled client did during a normal workday. The treating physician should personally
complete the APS and not merely hand it off to a medical secretary to fill in
the blanks from the client’s file. It
is also important that the treating physician be “appropriate” for the type of
disability. Companies frown on a GP or
Family Physician (as an example) treating your client who is severely
depressed, especially where “heavy duty” medications are involved.
Interview is another “tool” used during the process of many claims. Here, a field investigator will contact your
disabled client and typically ask for a 30-40 minute meeting to review
information the company has received from that client, his treating physician(s) and perhaps, other sources.
Questions related to incomplete information and any ongoing progress the
disabled insured is making would generally be the topic of conversation. If there are any real concerns about the
legitimacy of a claim, the field investigator will probe more deeply into all
aspects of the past and current activities of your disabled client.
Field investigators sometimes
don’t call in advance to make an appointment with the disabled insured. They may just show up at the door with, “I
was in your neighborhood and thought I’d stop by.” My advice to disabled clients is, if it’s not a convenient time, ask the field
investigator to make an appointment. A
disabled client of yours should never feel they are on the defensive side of
Video Surveillance is an
entirely different affair. I personally
look at them as a necessary tool but wonder how many times this tool is not
handled “properly.” Some claimants are
overly concerned about the use of video surveillance. They have heard the war stories from others who were denied disability
benefits for what seemed to be the misuse of this investigative tool. If a disabled
insured is claiming disability benefits due to a significant back injury a
video tape showing them lifting a large bag of fertilizer out of their Volvo is
not going to help the claim! Using the
reasoning, “it was one of my good days,” isn’t going to help either.
Insurance carriers understand the
nature of disability. If they suspect
someone is not being totally above board with them, and video surveillance might
help prove that fact, it’s going to be used. My biggest concern is when video
surveillance is used to establish a myopic view of a claimant. In addition, you should know that claimants
who live in gated communities are not immune to video surveillance. Investigators using video surveillance must
be careful not to engage in harassment and understand the laws regarding
invasion of privacy.
Independent Medical Examinations are a
“litmus test” to the validity of many claims.
If the attending physician states that your client is totally disabled
but does not submit adequate objective
information detailing the degree of disability, an IME will almost always be
asked for. In addition, in every claim
I have handled where mental or nervous conditions where the cause of
disability, an IME has been requested.
In several of these cases both a psychologist and psychiatrist were
The problem with IME’s is, I
don’t feel they are totally “independent.”
After all, the insurance carrier is paying to have these examinations
completed. In addition, there are a
growing number of physicians I’ve heard of who “specialize” in doing these
IME’s for insurance carriers. Thankfully,
every once in awhile, I hear of an IME that totally supports a claim but recently,
I reviewed the following case that heightened my concerns. The IME physician agreed with several treating physicians that the
claimant was indeed, totally disabled.
Several weeks after the insurer reviewed the IME report, it contacted
the IME physician and somehow, the company came away
from that conversation with a significantly negative view of the claim. This doesn’t leave me with a good feeling
about how the company is handling this particular claim.
Functional Capacity Evaluations are in
my opinion, “tests” not examinations.
Some attorneys I have spoken to contend that “examinations” are within
the scope of most disability
policies. However, “tests” may not
be. More important for you and your
client is the fact that FCE’s may exhaust that disabled client and in specific
situations, may actually inflict additional damage. I attending a litigation conference last year and one of the
guest speakers was as expert in training physical and occupational therapists
in work-related assessments and treatment (FCE’s).
She opened my eyes to the lack of
standardization and objectivity of many of these tests, which measure specific
performance of physical activities over a brief period of time and
extrapolating these results to an 8-hour day.
She questioned the consistency and reliability of these tests and the
lack of in-depth training of those who administer these tests. Your disabled client might well be advised
to resist this type of testing. At the
very least, have your clients attending physician know beforehand, that an FCE
is being asked for. The physician may
object to the test.
Financial Underwriting is
necessary in all residual disability claims, as these claims involve the loss
of income. When an insured applies for
disability benefits, the insurance carrier doesn’t know if the claim will prove
to be one for Total disability or Residual disability. The company will take into consideration the
definition of Residual Disability (assuming the policy includes residual) and
ask for past personal and business tax returns. This could amount to five years worth of previous tax
returns. That’s a great deal of
financial information for a CPA with perhaps, a forensic background to study
I feel this volume of information
isn’t really necessary when a clear-cut case can be made for total disability
from the initial filing of a claim.
Financial underwriting at the time of claim can however, provide a
picture of potential motivation for a disabled insured to remain on claim if
his or her business was troubled prior to disability.
The following is a list of what I
call “Red Flags” to potential claim problems for a disabled insured. These are
indications to the insurance carrier that further investigation might be called
symptoms without objective physical findings
Complaints of pain in excess of objective physical finding
& limitations not consistent with diagnosis
appropriate, claimant is not under regular care of a physician
certifying to disability outside cope of expertise
with medical recommendations
completing supplemental claim form and doctor signing it
doesn’t follow-up with recommendation to see a specialist
& O claim against disabled insured
missed medical appointments
close of business due to financial losses
discrepancies between treating physicians
objective medical testing to support claimed disability
appears to be doctor shopping
physician not in same geographic area as claimant
Next month I will walk you through a typical disability claim and provide additional advice that could help you and your disabled client. # # # # #