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What Is My Doctor's Role in My LTD Claim?

Going through the process of filing a short or long term disability claim can be confusing. It is important to understand that your treating doctor’s role in your LTD claim is critical. Not only is it important to provide the disability insurance company with your medical records, but you should also gather supportive statements from your doctors. This is because your doctor will be key in helping you get your benefits.

How to Get Your Doctors on Board

Before filing a claim for short term and long term disability benefits you should make an appointment with your doctor. During this appointment you should have a heart-to-heart and discuss your decision to stop working. Let your doctor know that he or she will be vital in your success for obtaining disability benefits. The insurance company will have their own doctors who will likely decide you are not disabled, you will need as much support as possible from your treating physicians.

The following steps may help you in getting your doctor to support your case:

  • When you make your appointment, ask the office to let your doctor know you want to discuss disability;
  • Bring in the necessary paperwork with you to your appointment;
  • Explain to your doctor why you need to file disability. Be as detailed as possible;
  • Inform your doctor that filing a disability claim can help you focus on your health and treatment and possibly improve your condition;
  • Provide your doctor with a copy of your job description and duties so he or she can better understand your situation.

If your doctor refuses to help, do not get discouraged. Try to re-explain your situation and see if he or she has a change of heart. Some physicians,however, will not get involved in a disability claim even if they think their patient should not work. If that is the case for you, seek out another doctor who is willing to support your disability claim and has treated your conditions.

Information You Can Get from Your Doctor

One of the most common reasons for a denial or termination of long term disability benefits is lack of proof of loss. This means there is not enough medical evidence to prove disability. Making sure your doctor will support your decision to file for disability benefits will increase your chances of an approval. Examples of documents that your doctor may need to complete or respond to during your long term disability claim include:

  • Attending Physician Statement;
  • Medical Questionnaires;
  • Letters of support;
  • Physician reviewer’s medical opinion;
  • Independent Medical Evaluation report; or
  • Functional Capacity Evaluation report.

You should know that sometimes your doctor will charge a fee to fill out disability forms or respond to the insurance company’s requests. Many times, however, supportive doctors do not charge a fee to their patients.

Treating Physician Rule & Doctor’s Opinions

In disability claims, the “Treating Physician Rule” stated that Administrative Law Judges (ALJ) should give “great weight” to the medical opinion of a treating physician when considering disability claims like LTD claims and Social Security Disability claims. A treating physician is defined as a doctor who has treated you throughout a continual doctor-patient relationship. The Treating Physician Rule acknowledged that the doctor who has spent the most time with you and your ailments will more than likely have the best idea of your limitations, even if the medical opinions of other experts are opposite because those medical experts do not know you specifically. However, this rule was changed in March 2017, so your treating physician is not automatically assumed to be better off understanding your disability than another medical practitioner brought into the case for a second doctor’s opinion.

The rule was challenged, in part, because treating physicians had to prove much less than a third-party expert in terms of medical understanding. To try to prop up the medical opinions of the doctors they hired or retained, an insurance company may go to great lengths to ensure that your treating physician is disregarded while your LTD claim is being evaluated. To give your treating physician, their medical opinion, and your chances of securing LTD benefits more strength, you should allow our LTD insurance attorneys to work on your case and support your treating physician’s input as needed.

What is a Peer Review Physician?

When an LTD insurance company wants to bring another medical provider into a case to check the work and medical opinion of your treating physician, they can hire a “peer review physician.” This physician does just what their title suggests: they peer review the work of another medical practitioner. While the concept of a peer review physician sounds fine, you should always beware of the legitimacy of any medical review completed by a physician who has been paid by an insurance company that wants nothing more than for your LTD benefits claim to end in their favor. The peer review physician could have been handed incomplete documentation, intentionally misled during an initial consultation, or been told to ignore certain parts of your medical records to reach the conclusion the insurance company wants.

How a Treating Physician Can Inadvertently Hurt Your Claim

Your treating physician should want the best for you. Unfortunately, wanting what is best and knowing what is best are not always the same thing, especially when a long-term disability insurance claim is involved. Insurance companies often look for treating physicians who are unfamiliar with the intricacies of LTD claims and try to get an answer or information from them that will ultimately and inadvertently hurt their patient’s best interests by leading to the denial of their LTD claim. Even when a treating physician’s medical opinion is that a patient is disabled, small misunderstandings can trigger a denial with big consequences.

A treating physician or doctor could inadvertently hurt your LTD claim by:

  • Approving sedentary work: Some medical providers might not understand an insurance company’s definition of sedentary work and think that their patient is capable of such work despite a disability. How an insurer defines sedentary work should be fully understood before a treating physician approves it.
  • Delay disability paperwork: There are times when a treating physician is hopeful that their patient will soon recover and be able to go back to work. Although this is ideal, it is not always realistic, and it becomes problematic if disability paperwork is delayed for this reason alone.
  • Overpromise treatments: A medical provider might not believe their patient will be disabled after a treatment course is completed, so they tell the insurer that they are not. However, if the treatment doesn’t cure the patient, then the patient will be disabled and be denied benefits based on the treating physician’s initial prognosis.

Disability Insurance Companies Tend to Ignore Treating Physicians

Unless your treating physician has inadvertently hurt your claim’s chances, the insurance company will probably do its best to ignore their medical opinions. Insurance companies prefer to use whatever information the peer review physician provides, even if they never examine you in person. ERISA law is what allows insurers to effectively set aside a treating physician’s medical opinion, no matter how clear, concise, and accurate it might be.

Under ERISA, insurance companies have “deference,” which means a judge can only rule against an insurance company if it acted completely unreasonably in denying benefits. Due to deference, an insurance company is not required to take the word of a treating physician over their own physicians. Courts have held that a disagreement between treating physicians and peer review physicians alone does not prove that the insurance company acted completely unreasonably.

Thus, it is not enough that your doctors are consistent in their diagnoses. The insurance company will likely have your records reviewed by their own doctors for any inconsistencies that could damage your claim. Our disability insurance lawyers are aware of this tactic and know what to do to counteract it in the appeals process or elsewhere.

Physician at work

Help from a Lawyer with Expertise in Disability Insurance

This law firm was built to be a disability insurance law firm.

That focus means:

Our disability lawyers can help you with:

Hiring an experienced disability attorney is important. Because federal law applies to most disability insurance claims, our lawyers do not have to be located in your state.

Call for a free consultation with an experienced disability attorney. Pay no fees or costs unless you get paid.

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