An insurance company’s decision to end a patient’s long-term disability benefits was upheld in a recent ruling due to his doctor’s poor post-appointment report. The case is a prime example of how something as simple as quickly dashed-off notes can be weaponized by insurance companies as evidence for a claim denial or cancellation.
The patient, formerly a radiology administrator at a hospital, was forced to leave his high-stress job after he developed cardiological complications. His benefits were cut off months later when the insurance company reviewed his latest post-appointment notes in which the doctor did not mention that the patient continued to be too disabled to work.
Under the patient’s insurance policy, simply being diagnosed with ongoing cardiological complications after a heart attack is not enough evidence to warrant continued benefits. The doctor must explicitly state that the patient is too incapacitated to return to work.
Per the ruling, “The mere existence of an impairment is insufficient proof of a disability…. A claimant bears the burden of proving that an impairment is disabling.” Even though the patient suffered another heart attack two months after the appointment in question, the court’s opinion was that the doctor’s notes did not support continued payment of long-term disability benefits. The insurance company’s decision to terminate his benefits was upheld.
The patient’s argument for continued long-term disability benefits was further damaged by an apparently casual comment during the appointment in question about retirement. The insurance company highlighted this comment as evidence that the patient no longer qualified for long-term disability under his employer’s insurance plan. Again, due to the lack of explicit notes in the post-appointment report, the court did not agree that the decision to retire was based solely on the patient’s medical condition.
The takeaway here is that care must be taken at each doctor visit while one is collecting long-term disability benefits. Specifically, the doctor must reaffirm during the appointment and in the post-visit notes that the patient is indeed still too disabled to return to work. As this ruling proves, the mere absence of this information in a doctor’s notes can theoretically carry enough weight for an insurance provider to legitimately end benefits.