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The Long-term Disability Medical Consultant review. What is it? What can be expected?

Attorney Cesar GavidiaAuthor: Attorney Cesar Gavidia

You’ve arrived home from your doctor visit and you check the mail and find that you have a letter from your long-term disability insurance company. The letter explains that the long-term disability carrier is in the process of conducting a medical consultant review of your claim. Your benefits have not been interrupted; however, the disability insurance carrier has reached out to your treating physicians to request medical records. The letter also states that their medical consultant may attempt to contact your physicians to discuss your claim.

This type of letter often prompts a person to immediately rush to their computer and begin punching search terms into Google, “long-term disability insurance medical review”, “disability insurance medical consultant”, “disability insurance denial following medical consultant review”, etc.

Should they be this concerned? Well, one can certainly understand why they would be. A quick search of the internet will prompt dozens of horror stories describing case after case where an insured’s long-term disability benefits were terminated or denied following a records review by a medical consultant.

What is a medical consultant review, and does it always lead to a denial of long-term disability benefits? First, a medical consultant review is just what it sounds like. A medical consultant review is conducted either by an in-house physician or nurse for the disability insurance carrier, or a physician or nurse contracted through a third-party company to conduct a review of your claim and medical records. The good news? Well, the good news is that a medical consultant review does not always lead to a termination of benefits or a denial of your long-term disability claim. Unfortunately however, it is certainly possible that it may.

Rarely does a disability insurance company decide to approve or deny a long-term disability claim without first having the records and other material reviewed by either an in-house medical consultant or third-party physician consultant. Furthermore, during the course of an approved long-term disability claim it is not uncommon for a disability insurance carrier to conduct a medical consultant review periodically, or conduct one if a change in the definition of disability is approaching.

The long-term disability carrier will begin by requesting and compiling your medical records. This is the part that is actually somewhat within the insured’s control, in the sense that the insured can ensure that their records are complete and accurate by frequently gathering and reviewing them. One mistake or typo in the medical records can mean the difference between receiving your monthly disability benefits or receiving a termination of claim letter.

As the medical records are compiled and gathered, the disability insurance carrier may also hire a private investigator to conduct video surveillance of the insured, so that the medical consultant can observe the insured’s mobility, behavior, and activity, as well as assess the veracity and consistency of their activity with their reported restrictions and limitations.

After the medical records and other information are received, the medical consultant begins their review. They begin by looking for immediate reasons for termination or denial, such as: gaps in medical treatment, non-compliance with prescription medication, to name a few. If it’s not apparent there are any significant gaps in medical treatment and the insured has been complaint with the doctor’s treatment plan then the consultant’s review will shift to the details of the doctor’s notes and records. The consultant is looking for specific areas in the records and notes that discuss the insured’s symptoms and how they correlate with the imposed and claimed restrictions and limitations.

What gives rise to the most concern is when the medical consultant contacts the treating physician to discuss and question them concerning the long-term disability claim. If your physician is not sufficiently familiar with your case, or worse, does not want to cooperate and will not support your long-term disability claim, the medical consultant and the long-term disability carrier can effortlessly obtain the justification needed to terminate or deny your benefits.

It is important to frequently and openly discuss your symptoms, restrictions and limitations with your treating physicians. It is imperative that your physicians are familiar with your complaints and symptoms and why, as a result of them, you are unable to work in your occupation, or in some cases, any gainful occupation.

Lastly, if a claimant receives a letter from their long-term disability insurance carrier informing them that the disability carrier has referred their claim to a medical consultant, the claimant can reach out to a long-term disability insurance attorney to discuss their options and what preemptive measures, if any, can be taken to avoid an interruption or denial of their long-term disability claim.

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

Chris K.:

A lifetime of earned benefits can vanish with a typo. This is what we are down to in the insurance industry, as well as with some state and federal regulatory agencies. You must be diligent to survive, and ask for professional help at the slightest turn.

Attorney Alex Palamara:

Chris, we are so empathetic to your situation. We see this on a regular basis. Insurance companies often deny claims when doctors make an accidental check mark on a form or misread a question on an Attending Physician Statement. Please feel free to contact me at your convenience so that we can discuss your claim and hopefully offer assistance for you.

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