Physicians are not usually English majors nor are they trained in insurance law. So, when they write medical reports for disability patients who require their help in dealing with insurance companies, doctors do not always meet the needs of their patients.
Doctors are busy people whose main objective is to heal the sick and injured. Most feel that ancillary duties, such as writing reports to disability insurance companies, are burdens which have to be borne and, in effect, interfere with their main function – healing. In other words, many of these physicians regard the need to file medical reports and evaluations with insurance companies as a bother and do not pay as much attention to them as they do to the healing arts.
But, a proper medical report may be just as important to a patient as is the cure, because it may hold the key to the patients’ wellbeing for the rest of the patient’s life. This is particularly true in the disability income insurance field where a patient guards his or her most valuable asset (the ability to earn) against the disaster of serious illness or injury.
A careless phrase or inexact description in a medical report may give an eager insurer the excuse to deny a disability income claimant and unwittingly bring the claimant’s world crashing down. This has happened many times to many patients and causes the misery of disability to be geometrically compounded.
Doctors have to realize, as DI lawyers do, that a disability income claim is usually a relatively large one for the insurer. Since a claim dollar saved is a claim dollar earned, one can’t blame the insurer for jumping on a report from a claimant’s physician which might seem to indicate that the patient is not disabled so as to qualify the patient for disability income insurance payments over the long haul.
And, if the claim falls under the jurisdiction of Employee’s Retirement Income Security Act, (ERISA), the advantage in a contested claim action is definitely with the insurance company. Insurance companies have full time staffs of lawyers and investigators who go over each claim and its supporting documents with a fine tooth comb. At the first hint of a discrepancy in the claim, the insurer has the right to deny it and put the claimant (the doctor’s patient) to the burden of proving the validity of the claim so as to make the insurer change its mind. And, this proof in Erisa is usually heard and determined by a hearing administrator chosen by the insurer.
You can just imagine the level of proof required to get the insurer to voluntarily change its mind and say, “OK, we’ll pay”.
What this means is that the patient and counsel must try to make the reporting physician understand the importance of clear and accurate reporting of the patient’s condition and prognosis. The doctor must know that carelessness and inattention are not an option and that the required reporting is just as much a part of the patient’s treatment as surgery or medication.
Once the doctor understands this, a cooperative, professional effort for the benefit of the client is easily achievable. If the physician will give the attorney a few minutes on the phone, the outline of what information is important to the insurer can be laid out so as to guide the doctor to provide complete, accurate, relevant data and opinions in the medical report.
The doctor may further be willing to provide the patient (and thereby the attorney) with a copy of a proposed report so that the patient and attorney may review it for accuracy and for any pertinent material which may have been omitted. Any such material should be suggested to the reporting physician for consideration for inclusion in the report.
It is vital that the patient and attorney be responsive to the needs of the physician in preparing the report. There should be no inordinate delays in reviewing and responding to a doctor’s suggested report. Further, no burdensome requests should be put forth to “gild the lily”. Only corrections or omissions which are thought to be necessary should be suggested and reasonable time parameters should be enforced on these suggestions.
It is obvious that a medical person will not be as familiar with the language of a disability income insurance policy as a lawyer practicing in that field of law. It is the task of the attorney, if given the opportunity, to explain the evaluation process of the insurer to the doctor so that the doctor files a report which answers the questions the insurer would have concerning the patient’s condition in the light of this evaluation process.
For example, a surgeon who develops a condition which causes his hands to shake involuntarily might be able to continue the practice of medicine but be unable to continue to practice as a surgeon. If the surgeon has a policy which insures against being unable to practice as a surgeon (generally a more lucrative practice), then a report stating that he can continue to work (in a general practice) would cause the patient all kinds of difficulty with the insurer even though the reporting physician finds that the surgeon clearly can no longer practice in the field of surgery.
If an insurer has such an incomplete report in its files, it will use it for all it is worth. Such a report puts a tougher burden on the shoulders of the patient to refute it and clarify its meaning. And, even the reporting doctor will have the burden of undoing a mistaken or incomplete report or prognosis.
Once people in the medical field realize that in a good many cases, wellbeing of the patient doesn’t end with the last office visit, they will give the requirements of reporting on disability claims the attention it deserves. This is especially true in disability income insurance matters because the requirements are often technical and the future peace of mind and wellbeing of the patient depends on it.
Cooperation between the two professions is in the best interests of the patient because it offers the best method for providing the required medical information in an accurate, complete and meaningful way.
You, the patient, deserve no less than this
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