In the last several months I’ve learned that there are many individuals who do not completely understand that private disability policies are double-edged swords. Not only does the definition of disability require medical certification, but that restrictions and limitations must relate to ones inability to work in some way.
The tendency today is for insureds to continuously submit medical “proof of claim” without connecting the dots between medical impairment and the inability to work. One without the other does not make a successful disability claim. Both criteria contained within the definition of disability must be addressed before most insurance companies will pay claims.
I have to admit that although there are some savvy physicians who know the private disability logo, and can write excellent restrictions and limitations for their patients, most are not adept at providing successful restrictions that link R&Ls to work capacity.
For example, one physician wrote (keeping this very simple), “This patient is permanently restricted from lifting > than 10 lbs.” Although technically, this is a medical restriction, it leaves out “occupational incapacity.”
Rephrased, it should read, “I’ve reviewed this patient’s job description requiring him to lift up to 20 lbs. frequently. Based on recent MRIs and the patient’s ten-year history, treatment and consultation with me, he is permanently restricted from lifting greater than 10 lbs. and is therefore not able to perform his material occupational duties. This restriction is permanent and is not likely to change in the long-term.”
The above phrasing is probably one of the best documentations of a medical “restriction” that links “medical cause and effect” to “occupational incapacity.” The unfortunate thing, however, is that most physicians will not take the time to write such a lengthy restriction even if he/she was aware of the dual requirement needed for private disability.
The key here is that physicians must ALWAYS link medical restrictions to key material and substantial duties that would preclude patients from working in any capacity. For some reason, the “occupational” definition of disability is often disregarded resulting in adverse claim decisions. This is particularly true when insureds attempt to manage their own claims.
Private disability is NOT determined by persuasive medical information alone, but also by documenting occupational requirements insureds and claimants can no longer meet. In the absence of “connecting the dots”, insurance companies keep going back to treating physicians in what appears as harassment in order to get answers to the question, “Why can’t this patient work?”, and “What parts of their jobs or occupations can’t they do?”
When I review IME reports (and I have reviewed thousands), questions posed to IME physicians are always the same: “What restrictions and limitations prevent this insured from working at his/her occupation?” “Would this person be able to work as a ——–full-time?”
Insurance companies always want to know if insureds and claimants can work. Most of the other risk management activities such as surveillance, field visits etc. are also wrapped around finding out why insureds can’t work for medical reasons.
In theory, insureds must meet both criteria of the definition of disability before benefits can be paid. In reality, most insurance companies pay claims for medical certification only, and then spend the entire history of the claim searching for the connection between medical restrictions and inability to work. This is why the claims process appears to be burdensome and vexatious since claims issues never seem to be resolved in any way.
Finally, insurance paper reviews are not all that persuasive representing only presumption, opinion, and circumstantial evidence. If treating physicians actually took the time to write good restrictions and limitations, most internal paper reviews would be disregarded since they do not represent “fact” or provide accurate assessments of work capacity.
BOTH medical restriction and occupational incapacity should be documented as “proof of claim.” One without the other could prove to be a very costly omission.
Consulting ServicesDisability Claims Solutions, Inc. is a fee based, national consulting organization that provides expert claims management services to those with private insurance. I offer free initial consultation.
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