Is Your Insurance Company Allowed to Disregard Your Doctor’s Statement That You Are Disabled?

By Scott E. Davis, Disability Attorney

Many people, as well as their medical professionals, mistakenly believe that when they file a claim for short and/or long-term disability benefits, their disability insurance company has to accept their medical professional’s (doctor’s) statement that they are disabled.  Common sense suggests this is a reasonable assumption – but it couldn’t be further from the truth.  Why? Because so many insurance companies simply do not want to pay people’s disability claims and when armed with discretionary language in the policy as they frequently are – the insurance company has the final and only say on whether you are disabled, not your doctor.

Making matters worse is the fact that the insurance company is operating under a conflict of interest when it evaluates your claim – remember it makes the decisions and also pays the claim if it approves it.

Even though my law firm has had tremendous success the past 18 years winning our client’s disability cases and getting their benefits paid, I remain fascinated and amazed at how frequently our client’s doctors’ statements that they are disabled are either flat out ignored or easily dismissed by the insurance company in favor of their own handpicked doctors’ opinions that you are fine and able to work.

A dirty secret in the disability insurance industry is that for many years, insurance companies have relied on outsourcing the ultimate opinion regarding whether a person is disabled to an alleged “independent” medical professional to make the decision, many of whom are frequently retained and earn a significant living from simply reviewing medical records.

Over the years, I have spoken with countless treating medical professionals who are also amazed that an insurance company can reject and disregard their opinion that their patient (my client) is unable to work.  A dirty secret in the disability insurance industry is that for many years, insurance companies have relied on outsourcing the ultimate opinion regarding whether a person is disabled to an alleged “independent” medical professional to make the decision, many of whom are frequently retained and earn a significant living from simply reviewing medical records.  The insurance company’s doctors will never see you, never examine you or have any idea who you are, what issues you deal with every day that prevent you from working – nope, instead they only look at your medical records.

Not surprisingly, these reviewing doctors know who butters their bread and as a result, they frequently conclude that you are fine and able to work.  Many people mistakenly assume that a doctor hired by the insurance company is truly independent and should agree with their treating medical professional; however, this is often not the case.  Indeed, the insurance company doctor may even call your doctor for a “peer to peer” phone call to make sure it provides a “full and fair” review as required by ERISA (the Employee Income Retirement Income Security Act) and also to give you every opportunity to get your claim approved.

Of course, the idea makes sense, who else knows your medical condition and inability to work better than your doctor, so why not call them.  However, my experience over the years is that the phone call is “window dressing” and a precursor to a denial because the insurance company doctor will write up their report simply disagreeing with your doctor.

Discretionary language means the insurance company has “discretion” to determine who is eligible for benefits and who is not – meaning that the decision can only be reversed by a federal court if there is an “abuse of discretion.”

The main culprit in why insurance companies have this type of powerful leverage over your claim is due to the fact that many employer provided disability insurance policies in the United Stated contain discretionary language.  Discretionary language means the insurance company has “discretion” to determine who is eligible for benefits and who is not – meaning that the decision can only be reversed by a federal court if there is an “abuse of discretion.”  A very powerful tool which allows any insurance company operating under a conflict of interest (remember, its makes the decision and also pays the claim if it approves it) to use to deny your claim.

Compounding the problem with discretionary language is that federal courts must uphold an insurance company’s denial of your claim if there is a “reasonable basis” for it.  Thus, the insurance company’s doctor provides that “reasonable basis,” and provides the illusion that you received a “full and fair review” as required under ERISA.

If your insurance company approves your disability claim you should be thrilled, it generally means the insurance company’s doctor agreed with your treating medical professionals.  If your claim has been denied, you have the ability to appeal under federal law and your success at eventually getting your claim approved will be based on how well you counter the reasons provided in the insurance company’s denial letter and showing that it was an unreasonable decision based on the evidence.

Make no mistake; you need a strategy and game plan along with experience at executing them with the same type of precision that the insurance company used to deny your claim.

Make no mistake; you need a strategy and game plan along with experience at executing them with the same type of precision that the insurance company used to deny your claim.  I have learned over many years the only way to do this is through an appeal that contains overwhelming medical, vocational and lay witness evidence.

If your claim has been denied, you need to get pro-active, get in the game and fight rather than give up.  Please do not let the insurance company run you over!

We have been beating insurance companies at their own game for the past 18 years, call us at (800) 588-1710, for a free consultation if your claim has been denied so you can put your mind at ease and learn how we can put you on a path to beat the insurance company at their own game.

© 2015  Scott E. Davis, Disability Attorney