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Who Makes The Decision To Deny A Long Term Disability Insurance Claim?



Attorney Gregory DellAuthor: Attorney Gregory Dell

Through my review of thousands of long term disability benefit denials, I can tell you that 98 out of 100 hundred times the disability insurance claims examiner will only believe and listen to what their own hired doctor states. This means that if three of your doctors say you are disabled and the insurance company has the medical records reviewed by their own doctor, then the insurance company will ignore your treating doctors and agree with the hired doctor. There is no requirement for the disability insurance company to give more weight to the medical opinions of the treating doctors, however the disability insurance company is required to conduct a fair and reasonable review of all available information.

How Can The Disability Company Conduct A Fair Review When 98% Percent Of The Time They Adopt The Opinion Of The Hired Doctor?

The answer is the disability insurance company hopes that by denying the long term disability claim they will force the claimant to return to work. The disability claim examiners have been trained to send all available medical records to their hired doctors and then adopt the opinion of the hired doctor. With some of the disability insurance companies, it appears that the claims examiner does not have the discretion to disagree with the hired doctor. While the claims examiner is the one that ultimately signs a denial letter, the claims examiner at most companies are really nothing more than paper facilitators seeking the opinions of hired doctors to the detriment of claimants. In my opinion it is the Hired Insurance Company doctor that makes the decision to deny a long term disability claim. Hired insurance company doctors do not always determine that claimants are not disabled. The vast majority of hired insurance company doctors have no understanding of either a claimant’s occupation or definition of disability. The lack of knowledge and cursory reviews conducted by these hired insurance doctors create great opportunities for a claimant obtain a claim reversal through either an appeal or law suit. Most disability companies will not have a claimant physically examined as they don’t have as much control over the doctors that actually do physical exams and the doctors that actually exam a claimant are compelled to conduct a thorough exam. The hired insurance doctors rarely conduct a thorough exam and often ignore medical records as they perform cursory medical exams and don’t really review the medical records. These careless medical exams give a claimant a good chance to win a reversal of a disability denial. If your long term disability claim has been denied or you have reason to believe that it may be denied, then please contact any of our long term disability lawyers for a free consultation.

There are 2 opinions so far. Add your comment now.

Denny:

I am sure you have seen & heard it all, but I wanted to share my own personal insights into Big Insurance (aka Reliance Standard, aka FRSL).I got initial denial letter in June 2016, of course 23 months after my initial acceptance of LTD in July 2014. I spoke with my rep and asked if I needed an attorney to appeal and was told no, I did not need an attorney for my initial appeal and should simply write my own personal appeal letter, along with a letter from my Primary Care Physician clearly stating my inability to be gainfully employed in any position. By the way, my rep and the Claims rep told me that my appeal was excellent and would be sufficient to continue my benefits, considering my medical condition.

FRSL denied my appeal in July 2016, and I requested an IME. The IME neurologist saw me a month later, however, FRSL was unable to contact him later for “clarification”, stating his report was incomplete. He did not state my ability or inability to hold a full-time job. I was also told the FRSL third-party vendor, MES Solutions, told them the IME doctor was retired and not taking any calls.

Therefore, FRSL requested MES find a “peer evaluation”, and within one week, another neurologist claimed that I was capable of full-time sedentary work, considering my education and background of 40+ years of work, including 10 years in the US Navy. When I searched for this neurologist and called his office, I was told that he also was retired and “moved back East.”

At that time, the Benefits Analyst told me that my file was closed and my only recourse was legal action.

This is when I contacted Dell & Schafer, after researching such cases on the internet. I found your excellent track record and victories over FRSL very attractive. Victor Pena is handling my case, but we have no chance of a second appeal under ERISA standards. I must say that I believe ERISA was written by the insurance companies for the insurance companies.

My only hope is that Victor’s suit is solid enough to tell FRSL will not receive a dime of my SSDI backpay and let me go. I have a hearing at SSA on December 1st, with my attorney from CA. That is another battle, waged now over 2 years, but we are very confident we will win this one.

In closing, I have learned a couple things: 1.) do NOT make any appeal with an insurance company on your own. HIRE an attorney and know you may be able to do so with no initial investment, and 2.) third party vendor and IME doctors are paid to say NO. No doubt in my mind that I could be in even worse condition and they would still say NO.

I hope & pray for a peaceful resolution to my case with Victor soon, although I have also learned the wheels are justice are very, very slow and weak.

ANTHONY:

I prayed that my appeal will be succesfull. I was also the victim of a medical peer review from. One of these doctors until we ordered a FCE…Aetna didn’t want to do an FCE…but your company assist me with one…hopefully they will resume my payments..i have lost so much my car, my credit my family…if we win i will want to settle for lumpsum

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