For a long-term disability claim, it is important that the medical records include accurate and thorough documentation of the claimant’s physical or mental condition. A doctor’s note stating the claimant’s disability is not enough for an insurance company to pay the claim. If the treatment records do not support the claim of disability, the insurer may deny the benefits. Insurance attorneys as well as insurers handling such claims require accurate medical review services to check the claimant’s eligibility for the benefits.
Apart from the physical injuries sustained in an accident, there are many medical conditions that may be eligible for disability payments from the insurer such as chronic illnesses, neurological disorders, and certain degenerative diseases. Sokolove Law has discussed some of the medical conditions that may qualify employees for long-term disability benefits that include cancer, bi-polar disorder, crohn’s disease, chronic fatigue syndrome, degenerative disc disease, fibromyalgia, HIV/AIDS, lupus and multiple sclerosis. Conditions may differ from policy to policy depending on how an insurance company defines a disability.
Key records that insurers require to prove long-term disability include the following.
Medical Evidence – Medical evidence can be objective or subjective. Objective evidence includes test results such as MRIs, X-rays and blood tests and clinical findings such as a rash, fever, swollen glands, red throat or restricted range of motion. At the same time, subjective evidence consists of recordings of a patient’s subjective complaints such as pain and fatigue. Subjective evidence is more credible when it corresponds with objective evidence, as for instance, an MRI showing a herniated disc, which corresponds to the patient’s subjective complaint of back pain. Insurers often insist on objective evidence to pay for disability.
Treatment Notes – Physicians record these progress notes during office visits. The insurance companies focus on these notes more than medical reports, as they are contemporaneously recorded. However, these notes often do not reflect everything the patient said. Doctors often include notes as a memory jogger and not for the insurer’s purpose. Also, patients may not report every condition during an office visit. For instance, they may report the pain they have, but not the fatigue. It is important for the treatment notes to include the conditions and symptoms that highlight the extent of the patient’s disability.
Treating Doctor’s Written Opinion – The treating doctor’s written opinion indicating the claimant’s disability from a sickness or injury is an essential evidence for the disability claim. Along with completing the insurer’s pre-printed Physician Statement, the treating doctor can be requested to complete a Residual Functional Capacity Questionnaire (“RFCQ”) prepared by the claimant. RFCQ mainly includes a checklist of possible symptoms related to a specific sickness or injury, medical signs and laboratory findings, a section for doctors to record the medications and side effects, describe the patient’s pain and fatigue, including the patient’s ability to sit, stand, walk, reach, twist and bend in a working environment. This can avoid the confusion of any incomplete treatment notes and Physician Statements. Residual Functional Capacity forms include questions about how much weight the patient can lift; how often, how far; whether they need to sit or lie down; whether they are likely to miss work; and the doctor has to fill out the forms circling the appropriate response and write notes clarifying their responses. A narrative report prepared by the doctor is another way to obtain the doctor’s opinion.
Chart Notes – Chart notes are valuable clinical documents that contain a complete record of the patient’s clinical data and medical history, and are documented by a physician, nurse, lab technician or any other member of the healthcare team. Medical record summaries for insurers or attorneys are created based on a detailed chart review that provides information regarding the various medical encounters of a patient. Long-term disability carriers use chart notes to determine whether the condition is a preexisting one, in which case the claim may be denied.
Reviewing diverse medical records for diverse cases can be time-consuming. Services of professional companies are available that provide accurate medical record reviews for insurance companies.
