I have recently reviewed first level appeal denial letters from Lincoln in which Lincoln appears to be relying on information through the website/software MDGuidelines as opposed to an internal medical review or a medical review performed by an outside peer reviewing physician. In both instances the initial denial of benefits was predicated upon the review of a doctor identified in the denial letter, to include the medical specialty of the reviewing doctor. However, after the insured submitted their first level of appeal, the denial letter only references a “healthcare consultant” with no provided credentials and then goes on to reference MDGuidelines as the medical review basis for its determination as to restrictions and limitations.
What is MD Guidelines?
A simple search of the internet reveals that MDGuidelines is owned and operated by the Reed Group, a known third party administrator for many company’s short term disability policies. Per their website, www.mdguidelines.com:
THE MEASURE OF HEALTH
Better care, better outcomes and lower costs are better for everyone. Now Reed Group can help you get there.
Reed Group’s MDGuidelines is the industry’s most trusted solution for impacting evidence-based care across entire populations- safely returning individuals to active living quickly and helping organizations thrive.
Essentially, MDGuidelines is a “plug and play” software in which an insurer, third party administrator, or employer can essentially indicate someone’s diagnosis(es), occupational duties, and medical symptoms to determine the “reasonable rate of recovery” when someone should be cleared for work. Per the MDGuidelines website:
Integrating physiological duration tables with the American College of Occupational and Environmental Medicine’s (ACOEM) evidence-based treatment guidelines, robust analytics and clinical expertise, Reed Group’s MDGuidelines is essential for better decision-making, case management and health outcomes. For ACOs and other organizations transitioning to value-based care models, MDGuidelines also delivers intelligent clinical decision support at the point of care. This unique combination of content, tools and protocols aligns all stakeholders toward common goals by helping to:
- Improve care consistency and outcomes
- Eliminate costly variations in care
- Optimize utilization of services
- Promote the delivery of high-quality care
- Quantify the financial impact of reducing care durations
- Strengthen relationships between providers, insurers and employers
What does this mean to disability insurance claimants/insureds?
As a disability insurance attorney who has represented countless people over the span of a decade seeing a major insurance carrier (who mind you just acquired Liberty Mutual’s disability and life insurance policies that fall under the umbrella of Liberty Life Assurance Company of Boston and has thus drastically increased its presence in the group benefits market) rely on such software is quite troubling. An individual’s complete medical history as it relates to the ability to perform work duties is incredibly complex. Diagnoses and applicable restrictions and limitations are determined through objective medical testing, clinical examination, and the medical opinions of the actual doctors who treat a patient- and should not be determined by software whose sole purpose is to return people to work.
In one of the aforementioned denial letters referenced above, it appears that Lincoln did not have any peer review doctor review the appeal information and instead relied almost exclusively on the MDGuidelines program. This is highly unusual from what our office has experienced and witnessed with Lincoln’s review of disability appeals, and even calls into question the level of compliance with ERISA in providing a full and fair review on appeal. One Lincoln denial letter states:
We evaluated this claim by applying the provisions of the policy to the facts and opinions contained in the claim file. We relied upon the following guidelines, internal rules, protocols, standards of other similar criteria in reaching this claim determination: MD Guidelines are utilized to evaluate a specific recovery period for a condition or procedure based upon the physical demand level of the occupation in which the insured was working prior to disability MD Guidelines is used in the instance when complete agreement is not obtained by all parties with regard to appropriate recovery period/return to work. The expected duration of disability for your condition or procedure, taking into account your occupation is 0 to 5 days.
For reference, the particular denial letter in which this language was found was for an insured who had already been on claim and deemed disabled by Lincoln in excess of a year. The above language leads anyone to believe that had Lincoln employed the MDGuidelines sooner the insured would not have even satisfied the short term disability elimination period.
In an area of law that is already rife with discrepancies in fairness; that does not allow an insured to testify at their own “trial;” that does not require an insurance carrier to have an actual doctor examine an insured; that does not allow a reviewing judge to provide more credibility and weight to the opinion of an insured’s treating physician; and that does not allow for insurance companies to be punished by way of extra contractual damages for its actions – this latest apparent trend to use “plug and play” software only adds additional insult to injury and increases the likelihood and risk that more disability insurance claims will be denied.
If you have a disability insurance claim with Lincoln, or any other disability insurance carrier, and you receive information that your claim is being reviewed using programs such as MDGuidelines, or have any other questions about your claims, please do not hesitate to contact our office to speak to one of our disability insurance attorneys.