Disability Insurance Blog

Who decides if you are disabled?


Friday, September 16th, 2016

If you have filed a disability claim with the disability insurance company that you purchased a policy from privately, or if your disability insurance is part of your employee benefits plan, you may be surprised to learn that in either case, it is not your treating physician who makes the final determination as to whether or not you are disabled.

And sometimes, it’s not even the disability insurance company.

There is an entire industry of companies whose sole purpose is to examine claims and, from our perspective, look for ways to deny them. They are known as “Third Party Administrators,” and they are big businesses, employing nurses and doctors who no longer see patients. Instead, they pore over the medical records provided by the insurance companies. One of the common reasons we see for denials stem from “paper reviews,” where doctors, nurses and sometimes people who are not even medical professionals review your medical records.

Often, the insurance companies only provide select parts of your medical records to these reviewers. No one can give an accurate review of a medical record if they are only looking at a portion of medical records. This is particularly true when the claimant is not even examined. And often, we also find that the medical reports from leading specialists in advanced fields of medicine are discounted by people who have little understanding of these medical specialties or the nuanced medical issues involved.

Whether or not you are disabled is also determined by the so-called Independent Medical Examination, or IME. Many of the doctors who we come into contact with are no longer practicing medicine; all they do is evaluate claimants who are sent to them by the disability insurance company. At least in this case there is an actual person being examined – as opposed to the pure paper only medical review.

The problem here is however, that the doctors are being paid by the disability insurance company. They can hardly be expected to be impartial, when the insurance companies can make or break their business. If too many people are found to truly be disabled, will the doctors see this new revenue source dry up? We can’t answer that – but we have our suspicions.

Disability insurance companies are like any other insurance companies: they make money from their portfolio investments, which are considerable. They also make money from the sale of insurance policies. They lose money when markets are down, interest rates are low, and when they have to pay out claims. Thus, reducing their paid claims is an important feature of how the company’s profits are.

As you can imagine, it is not profitable for a company to pay out benefits without doing due diligence to make sure that claimants are genuinely disabled. That makes sense, and we understand it. But as attorneys representing people who have been wrongly denied their benefits, we know that many of these claims are not being properly reviewed. Instead, claimants are subjected to biased medical reviews, unqualified medical reviews and examinations by doctors whose loyalty is to the disability insurance company.

If your claim is being denied or delayed, call our office at 877-LTD-CLAIM (877-583-2524) to learn how we can help.