The use of medical record reviews is not new. Insurance companies utilize medical reviews in order to assess the validity of Long Term Disability claims. These are performed by medical professionals of all kinds. Unfortunately, these ‘professionals’ are paid for their opinions by the insurance companies, and often feel that a foregone conclusion to deny is assumed.
Medical Record Reviews and Their Effect on the Outcome of Your Long Term Disability Claim
More recently, the requirements of the administration process in relation to these reviews have changed. Plaintiff attorneys have been arguing at the unjustness of a medical review without an opportunity to respond prior to the rendering of benefits determination by the assigned claims representative. Now the medical review must be presented to the claimant prior to the rendering of a benefit determination as a claims representative relies on the review in making their determination and inherent flaws of the review or objections to the mode of review may be made part of the record prior to that determination being made. However, this opportunity to respond is not always honored by claims representatives and denial letters are routinely received by our law firm without being afforded the opportunity to respond to the review.
Despite the formality of an opportunity to respond to the review performed prior to a disability benefits determination, the opportunity to
meaningfully respond may still be illusory. The undersigned has found that the letter which includes this medical record review is usually comprised of the language almost exactly which will be used for the adverse determination letter.
In light of that fact, the new requirement often functions only to delay the claims process as a whole. Furthermore, claims representatives often use medical professionals not qualified to overturn the presumption of deference to the opinion of the claimant’s treating physicians, who are usually specialists in their field. For example, insurance companies frequently utilize occupational medicine physicians to review claims. While these physicians may speak somewhat to the functional impairment that certain conditions may have, they lack the specialized knowledge that treating, board certified in their respective field, physicians will offer.
Call Herbert M. Hill, P.A. for Assistance with Denied Long Term Disability Claims
If you are presented with a medical record review and given an opportunity to respond, this almost certainly will result in a denial of your claim. Only once has the undersigned seen the overturning of a claim at this juncture in the claims process. For this reason, it is an opportune time to hire an attorney, as the claims process will be ongoing and your ability to ensure the most aggressive evidence in on the record will be diminished.
