Disability Insurance Claim Advice
Recent Claims Department Trends
California Broker, January 2018
By Art Fries
As a disability claim consultant, I’m sorry to report that I’ve been seeing a trend to delay payment of claims through various harassing methods with the purpose of “floating money.” I believe these tactics allow the insurance company to hold on the money and earn interest on that money before they have to pay funds for legitimate disability claims. In addition, there are some other harassing techniques that anyone servicing clients should be aware of. These techniques are being used on existing disability claims for the purpose of terminating the claim.
USING P.O BOXES
Sometimes the claims department doesn’t provide a street address to submit claim forms, but instead provides a post office box. This increases the chance that a claimant will send in claim forms without requiring a signature of receipt. Quite obviously, you can’t get someone to sign off if it’s a post office box. This means there’s no evidence that the insurance company receives the claim forms and there’s ample opportunity for the claim department to say they “never received the forms.” Often the claimant will not follow up for a month or more. They will then be forced to complete a new set of claim forms and secure another attending physician statement, which causes more delays. This delay tactic can buy the insurance company an additional two months or more holding onto funds meant for the insured claimant.
MEDICAL FILES
In prior years, disability claim departments secured medical record through outsourced companies as follows:
The outsourced company would call the doctor’s office and ask the required fee to secure medical records for the claimant. They would then make an appointment to be at the medical office with the payment along with a copy of a signed authorization from the claimant (provided to the insurance company with the initial claim application). This enabled the company to secure a complete copy of the medical files. Typically, the “photocopy service” would bring their own equipment to the doc’s office. At one time, it was a portable photocopy machine, then microfilm. In more recent years, it was a laptop computer. This process was quick and effective and enabled the insurance company to secure medical records in a timely fashion.
The outsourced company would call the doctor’s office and ask the required fee to secure medical records for the claimant. They would then make an appointment to be at the medical office with the payment along with a copy of a signed authorization from the claimant (provided to the insurance company with the initial claim application). This enabled the company to secure a complete copy of the medical files. Typically, the “photocopy service” would bring their own equipment to the doc’s office. At one time, it was a portable photocopy machine, then microfilm. In more recent years, it was a laptop computer. This process was quick and effective and enabled the insurance company to secure medical records in a timely fashion.
Now, most of the claim departments use a service that faxes a cover memo and the signed authorization to the medical office requesting the records with no payment. If there are only several pages of medical records, the doc’s office might fax back the records. But say there are 20 pages…or 60 or 80 pages of medical records. In this case, the doc’s office will typically ignore the request or toss it in the patient’s file/computer file or possibly in the waste paper basket. Now multiply this procedure by the claimant having multiple medical providers – six or seven or more. You can see how long a claim department can delay matters as it relates to securing medical records. What previously took several weeks can now take several months or more before the medical records are received by the insurance company. In this scenario, the insurance company saves money in two ways. They cut no check to the medical office and they reap the benefits of many months of delay.
ATTENDING PHYSICIAN STATEMENTS
For many years, claim departments only requested one attending physician statement (APS). Now I’m seeing more and more claim departments requesting an APS be completed by all of the claimant’s medical providers listed on their initial claim forms. I am also seeing the same thing on “continuation forms” for existing disability claims. This is a great opportunity for the insurance company to secure conflicting opinions, creating further delays. Some physicians may not even agree to provide an APS. This great opportunity can provide the claim department three reasons for denial or termination of disability claims: 1) no support of the claim from one or more doctors; 2) conflicting opinions; 3) no return of forms (APS).
MORE CLAIM REVIEW
In addition to your claim representative who controls your claim, there are various “layers” of individuals such as nurse practitioners, accountants, physicians, occupational consultants, and others who specialize in various aspects of reviewing your claim. These individuals have never seen or spoken with the claimant. One of these specialists (often a physician) will try to contact one of the treating physicians to “trick them” in such a way that the doctor provides an opinion that is in conflict with the claimant’s medical records. Or they may try to request from the claimant’s doctor permission to secure an F.C.E. (Functional Capacity Evaluation) by someone hired by the insurance company even though policy contractual language my not permit such a test. The training – education and ability to interpret raw data correctly – by a physical therapist or occupational consultant performing an F.C.E. can also influence opinion provided to the insurance company.
MASSAGING THE FILE
Even long-term disability claims may not be safe from termination. Claim review people get moved around, promoted or leave the company, whereby a new claim rep is involved with the claimant’s file. Usually they do not have time to read the entire claim file from the beginning. They may call a claimant who has been submitting a continuation form/progress report and a continuation attending physician statement on a semi-annual or annual basis and tell them they should be submitting these forms more frequently. The claimant may have had an I.M.E. (Independent Medical Evaluation) 6 months prior or 1 year prior, but because the claim rep only glanced at the file, they are not aware of it. So, they will tell the claimant that another I.M.E. is going to be done. There are other harassing techniques used by claim reps, but these are two good examples.
MORE USE OF SOCIAL MEDIA TO CREATE A GOTCHA
Insurance companies have used video surveillance techniques for many years, especially in connection with musculoskeletal claims involving cervical, thoracic and lumbar areas. Claims related to shoulders, arms, and hands/fingers are also quite common. But even depression claims have not escaped the wrath of video surveillance. The purpose of these techniques is to gather information that shows the claimant doing something that may be in conflict with their claimed medical symptoms. This could be detrimental to the claim, which in turn can be the basis of a denial or termination. However, these investigative techniques have become increasingly expensive. But social media, such as Facebook, LinkedIn, Twitter, Google, Snapchat and other platforms are available to insurance company claim departments. They enable the claim department to view how you are conducting your personal life, etc., and to determine if there are any conflicts with your claimed medical condition. So a claimant now has to give more thought to how much time they spend on these platforms and what they say. I’ve often wondered how an insurance company has found out about my client’s vacation time frame and even when long distances are involved. Cyber checks might save an insurance company vast sums of money where there is no longer a necessity to pay outsourced video surveillance people sums of money to track a “high monthly benefit” claimant going on an Asian or European vacation. Maybe drones will be used in the future to capture a claimant’s activities even. Your guess is as good as mine, but this method of surveillance is certainly being considered and may be commonplace in the future.
As a disability claim consultant for the past 22 years, I have seen many changes and those I have discussed are some of the more challenging ones. Yet, they cause me to stay a step ahead of the insurance companies and offer combatant tools to my clients so that their disability claim is paid and solidified over the long haul.
