Disability Insurance Blog

Why Was My Long Term Disability Claim Denied?


Thursday, August 27th, 2015

Your claim may have been denied based on what is known as an “on-paper” medical review.

This is also known in the industry as a “peer review”.

We agree that it is infuriating to have a claim denied on the basis of a report from a doctor who has never seen, treated, evaluated or examined you.

Many disability insurance companies rely on outside companies or individuals to review claims – but not to conduct actual patient examinations. Sometimes these reviews are done by doctors or nurses, but remember, they are being paid by an insurance company, so in our experience, these individuals are biased against the claimant.

Two issues appear often when paper medical reviews are used to deny claims:

The medical records reviewed are often incomplete. Our firm has had many clients whose denials were based on reviews that did not include key diagnostic reports. How could this information be left out of the records given to the person or company reviewing the file? In our experience, this is sometimes a result of sheer incompetence. Other times, we think it may be deliberate, but this is not easy to prove.

The medical records are often reviewed by people who are not qualified. One of our clients suffered from debilitating migraine and cluster headaches. The doctor reviewing his records was known to us as an insurance company reviewer who consistently finds patients not to be disabled. In addition, he had absolutely no experience in the area of migraine headaches.

It seems illogical to make a decision on a disability claim without even seeing the patient in person. This is a decision that can devastate a family for years to come, and it seems that the exam should be given with a great deal of deliberation and caution. Nonetheless, many courts have determined that such conduct is acceptable, if not ideal.

A paper review cannot possibly provide a complete and thorough exam of a person’s health. And yet, we also know that claimants are also frequently denied following an in-person examination by insurance company doctors.

If you are contemplating filing a disability claim, make sure that your medical records have been reviewed by an attorney who is familiar with the “on paper” medical review. This way if such a review is done, your medical file will be properly prepared. If your claim has been denied based on a paper review, call our office to discuss your situation.