Disability Insurance Claim Advice
Tips on Self-Reported Symptoms and Record Keeping as They Relate to a Disability Claim
California Broker, December, 2012
By Arthur L. Fries, RHU
The most flagrant example of self-reported symptoms occurred in a telephone call to me by a physician (Internist), “Art, I think I’m going to have a psych claim and I understand you can give me advice to make it work.” My questions were the following:
- Are you seeing a psychiatrist or psychologist in terms of treatment?
- When did your symptoms begin? How long have you had symptoms and what specifically is the diagnosis? How do you feel now and is the treatment helping?
- Have you had to reduce your hours because of the symptoms?
His response, “Art, I’m not seeing any type of therapist. I don’t have any symptoms but practicing medicine is no longer any fun. Because of managed care I’m told what I’ll be paid and how to practice. I’d like to collect on my disability policy and I understand that you’re the guy that can make that happen.” My response, “I don’t do that. If you don’t have a legitimate claim, that’s fraud. Get another job if you no longer like practicing medicine.”
In most individual disability policies the words “self-reported symptoms” are not used. Neither are the words “subjective or objective medical symptoms” included in these policies. Most of the broader worded individual disability policies say, in essence, that you are sick or hurt (accident) and cannot perform the substantial and material duties of your occupation (meaning you can’t do your thing).
Some of the newer individual disability policies and many of the group disability policies do discuss self-reported symptoms for which limited benefits are provided, such as back pain, headaches, etc. (one or two years). There are, of course, exceptions and these are stated in the policy. Often, the word “objective” is used, meaning that there is some evidence, in the form of an MRI or x-ray, to lend credibility to the claim. Some policies say that you must be under the care of a physician who is appropriate for the condition. It’s always a good idea, anyway, to see the proper specialist for your medical condition.
It’s also a good idea to keep some type of history related to your condition from the beginning. That history should explain how you felt at your worst and how the condition worsened over time. You should also indicate in your history the effect your medical condition (symptom or symptoms) has on your job or profession. When you see medical providers, you should be specific as to your symptoms and how they are affecting your job duties. Don’t hold back your true feelings because you are concerned about what’s on record. Poor record keeping can also influence your disability claim. Even though you say you are a dentist, the insurance company wants proof in the way of tax returns as well as procedure codes.
Tax Returns
You may have been overly aggressive with respect to business expenses shown on your tax return. An insurance company forensic accountant can often find areas in your tax returns in which they feel are not legitimate business expenses. Your accountant might argue these issues but some times, you do not have the paperwork to back up the deductions and the insurance company will reduce the amount of business expenses being claimed on your tax return. A threat to go to the IRS will often cause you to back down and accept their findings.
Procedure Codes
These will determine the type of procedures performed and provide information to the insurance company with respect to how active you have been at your profession. Typical will be a request for computer printouts for the entire on-year period prior to your partial or total disability claim. Let’s say that you told the insurance company that you reduced your hours in half because of symptoms related to your cervical area, but your procedure codes show activity typical of one who has cut back only 20% when comparing your prior codes to your post (partial) disability codes. This inconsistency can be the basis for the insurance company to pay a lesser amount on your partial claim.
Self-reported symptoms and record keeping are just two areas of many that can have an influence on the outcome of your disability claim.
