The Disconnects Between Diagnosis and Disability

One of the biggest issues our clients face when filing their disability claim is the lack of clear medical opinions explicitly linking their condition to their disabling restrictions and limitations.  Physicians are skilled at diagnosing a disease or illness, but they may not be the best at explaining why the condition is disabling for the claimant.  This can especially be problematic with mental illnesses or other types of invisible disabilities.  Any ambiguities cause increased scrutiny and in-house referrals by claim examiners and are often used as a basis for a disability claim denial.  Helping your doctor connect the dots between your condition and your inability to work smooths the disability claims process and fosters a quicker claim approval with fewer questions.  We’d like to discuss two perspectives to this issue: the claimant’s and the physician’s.  We’re going to discuss what each party can do to make the disability clearer and the claims process smoother.  

The Attending Physician

physicianThere are two halves of a diagnosis that make up the whole picture for the insurance company. The claims examiner wants to see evidence (and preferably, although they don’t use the phrase much anymore, objective medical evidence) of the condition and proof the condition is in fact disabling. While using generally accepted protocols to make a fact-based diagnosis for the condition is common, proving to a reasonable standard that the condition is disabling is much more difficult, especially when looking at the claim through the eyes of a claims examiner.  Medical consultants, not necessarily doctors but nurses and case managers, are hired by the insurance claims defense industry who will take hard-line stances against the diagnosis of the condition and/or the assessment of disability. This is especially true in claims of people who are suffering from invisible disabilities.  The lack of objective and measurable testing for many such conditions leaves much up to the interpretation of the claim professionals reviewing the claim for the insurance company, allowing them to impeach the opinion of the attending physician, disregard evidence, and fail to find support for the claimed disability.

The first step in proving a disability resulting from a subjective diagnosis depends on the condition itself.  For medical professionals who treat mental illnesses and invisible disabilities, they’re already comfortable dealing with somewhat ambiguous issues and concerns.  If a patient is involved in the disability claim process, the doctor should be on the lookout for any tests or second opinions from specialists that may help “prove” the diagnosis.

The notes and comments recorded by attending physicians greatly impact the ability of their records to provide convincing evidence not just for the condition but also for the disability. When writing their notes, attending physicians should make sure they’re drawing a clear cause and effect linkage between any test results and clinical observations to the restrictions placed on the patient from performing the activities of their type of job. It’s also important to make sure any off-hand comments or notes by the doctor are clarified and put into context so they can’t be misconstrued by the insurance company. Many patients can also help with some of the record keeping burden to produce medical records that are appropriate and supportive in the disability claim process.  

The Claimant

disability claimantThe decisions a claimant makes in choosing their treating medical professionals can help or hurt their disability claim more than any other single factor.  Not arranging to obtain appropriate care and treatment for their condition or choosing a physician who’s not sympathetic to helping with the disability claims process can create roadblocks for any disability claim, so it’s in the claimant’s interests to take the time and effort to choose appropriate medical professional(s) and to help them prove your claim. There are several steps a claimant can take to help their attending physician.

A claimant must first be completely honest with their attending physician.  Prepare a detailed and thorough list of your limitations – make sure not to leave out (or exaggerate) any symptoms.  Most doctors are on your side, so there’s no reason to stretch to obtain a certain diagnosis. Certain tests can be discretely administered to see if patients are making a good faith effort, and claimants may lose the support of the medical professional who would have otherwise been sympathetic to their claim. Once you’ve chosen your medical professionals, allow them to properly diagnose you and generate records that are supportive, complete, and accurate, even if the insurance company pushes back against them. For example, if you’re suffering from conditions such as Fibromyalgia or Chronic Fatigue Syndrome/CFIDS, try to be more descriptive and specific when describing pain instead of using general phrases such as all over or all of the time. These statements don’t necessarily help your doctor with a diagnosis and can be exploited by the disability insurer.  

We’ve mentioned this subject before but it’s worth repeating – it’s also a great idea to go over each claim form the doctor must complete and submit on your behalf. Like mentioned above, doctors are very good at examining symptoms and diagnosing conditions, but they aren’t necessarily trained in connecting these facts to a disability. Make sure they really understand the extent that your medical condition has disabled you from your day-to-day activities and that the information is recorded in their notes and reported on the claim forms. Physicians are very busy and filling out claim forms is just not that high on their list of preferred activities. Incomplete and/or incorrect claim forms are all too common. In order to prevent these costly mistakes, you may want to consider even pre-completing some of the claim forms and having the doctor review the information to make sure it’s correct. Be sure to confirm that your doctor is open to this before you fill out the forms. The information on the forms must be complete and accurate to the best of your knowledge.  If you don’t know an answer, don’t guess.  And never put anything down that would cause your doctor to doubt you or your motives.

Claimants can obtain treatment from any medical professionals but should make sure to include one who is a specialist in the specific medical condition, trained and experienced in diagnosing and treating the condition.  While many doctors are fully capable of treating and diagnosing wide varieties of conditions, specialists may have access to additional testing not commonly available as well as a more in-depth knowledge of the condition.  A bonus may be if they’re experienced in the disability claim process from prior patients.  An example may be of claimants suffering from depression or chronic Lyme disease who consult a neuro-psychologist. While there are basic tests to prove both of these conditions, some neuro-psychologists can test and provide additional supporting evidence of the impacts of the disability on the claimant. This can produce more support that’s harder for the insurance company to impeach or ignore. It also prevents the insurance company from asserting that the claimant was failing to receive proper care and treatment.

Our firm sees many claims denied or delayed because of incomplete medical evidence or a lack of evidence tying the medical condition to the claimed disability.  Claims examiners often make a version of this argument:  “The records don’t prove you’re sick, and even if you are, we don’t believe your alleged sickness makes you disabled.”  While you can and should fight this accusation after receiving a denial letter or a letter asking for more information, it’s best to simply work to provide all of the information needed to prove your claim at the beginning of the process. Submitting a well-organized claim with complete medical records that prove your medical condition and demonstrate how you’re prevented from performing the duties of your job provide a great defense against the on-going attacks of the disability insurance company.

If you have any questions about how your medical records portray your disability or how to best submit claim forms, please sign up for a free consultation on our website or call us toll-free at (855) 828-4100.

6 pings

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