Medical evidence serves as the foundation of any long term disability claim, providing objective proof of an individual's disability and its impact on their ability to work. Insurance companies rely heavily on this evidence to assess the validity of claims. However, the interpretation of medical records can sometimes lead to disputes, especially if the insurer's evaluation differs from that of the claimant's treating providers.
To strengthen a long term disability claim, at a minimum, it's essential to provide comprehensive medical documentation, including:
- Detailed Physician Statements: Explicit descriptions of diagnoses, treatment plans, and prognoses.
- Objective Test Results: Results from imaging studies, laboratory tests, and functional assessments that substantiate the diagnosis.
- Treatment Histories: Records of past and ongoing treatments, their outcomes, and any side effects experienced.
Thorough and well-organized medical evidence can preemptively address potential concerns from disability insurers and provide a solid basis for appeals if necessary.
Addressing Delays and Denials
When faced with delays or denials, it's crucial to understand the insurer's rationale. Common reasons cited include insufficient medical evidence, discrepancies in documentation, or conclusions drawn from peer reviews conducted by the insurer's medical consultants.
To effectively counter these challenges:
- Request a Detailed Explanation: Obtain a comprehensive understanding of the reasons behind the delay or denial.
- Identify Discrepancies: Review the insurer's feedback to pinpoint specific areas where additional information or clarification is needed.
- Supplement with Additional Evidence: Provide further medical records, specialist opinions, or independent evaluations, such as a functional capacity evaluation to address the insurer's concerns directly.
- Engage Legal Expertise: Consult with attorneys specializing in LTD claims to navigate the appeals process effectively.
Proactive and informed responses can significantly enhance the likelihood of overturning a denial or expediting a delayed claim.
Case Study: Miller v. PNC Disability Plan
A pertinent example illustrating the importance of robust medical evidence is the case of Miller v. PNC Disability Plan, a case our firm won in federal court. In this case, our client suffered from degenerative disc disease, leading to chronic pain and necessitating five back surgeries. Initially, Liberty Mutual, the insurer overseeing PNC's disability claims, approved her benefits but later terminated them based on a peer review conducted by their medical consultant.
The peer review concluded that the claimant was not disabled, despite substantial medical evidence to the contrary. In response, the claimant, represented by Dabdoub Law Firm, appealed the decision, emphasizing the extensive surgical history and ongoing debilitating pain. The federal court ruled in favor of the claimant, highlighting that the multiple surgeries and consistent medical documentation provided overwhelming evidence of disability. This ruling not only reinstated the claimant's benefits but also set a precedent highlighting the weight of comprehensive medical evidence in LTD claims.
This case exemplifies how detailed and consistent medical documentation, coupled with exert legal representation, can effectively challenge unjust denials based on insurer-conducted peer reviews.
Best Practices for Long Term Disability Claimants
To enhance the strength of an LTD claim and mitigate the risk of delays or denials:
- Maintain Open Communication with Healthcare Providers: Ensure that your physicians are aware of the specific requirements and documentation standards of your LTD policy.
- Document All Medical Interactions: Keep detailed records of all medical appointments, treatments, and communications related to your condition.
- Be Consistent in Reporting Symptoms: Provide consistent and accurate descriptions of your symptoms and their impact on daily activities to all medical professionals involved.
- Seek Specialized Legal Counsel: Engage attorneys with a focus on LTD claims to guide you through the process, from initial application to potential litigation.
Conclusion
Don’t let insufficient medical evidence jeopardize your long-term disability claim. If you’ve experienced a delay or denial, the right documentation and skilled legal representation can make all the difference. At Dabdoub Law Firm, we focus exclusively on disability insurance claims and have a proven track record, including victories like Miller v. PNC Disability Plan.
Contact us today for a free consultation and let us help you strengthen your claim, challenge unfair denials, and secure the benefits you deserve.