What Is A Medical Consultant Review Request By A Disability Insurance Company?

You’ve arrived home from your doctor visit and you check the mail and find that you’ve 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.

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There are 4 comments

  • DR, I am sad to hear of your experience at the Independent Medical Examination (IME). Very often I hear similar reports regarding these “independent” doctors. Although it sounds like a denial will be forthcoming, the laws governing your claim allow us to file an appeal and to challenge this denial. As such, as your IME is still fresh in your memory, I would write down as many notes as possible. Part of your appeal might be to show Hartford how much of a sham that IME was. To help prevent a denial, you might try to submit any more supportive medical documentation you can get your hands on to help further prove your claim. Should Hartford deny your claim, please do not hesitate to contact me. I will gladly offer you a free consultation and review the denial letter.

    Alex PalamaraSep 11, 2019  #4

  • I have been receiving LTD from the Hartford since 2009, I have been receiving letters over the past several months asking for more medical records and was required to go to an “independent “ Dr. hired by the insurance company. I just came back from the appointment and it did not go well.

    The appointment lasted 15 minutes, he would cut me off when I tried explaining my different conditions and his final statement to me… you need to quit going to the Dr’s, quit taking the medicine, have the Spinal Chord Stimulator Implant removed and just excercize and meditate and you will be better. I was stunned… he basically said I was making myself sick. I know where this is going… the Hartford will most likely be cutting me off. Help!

    DRSep 11, 2019  #3

  • Todd, it was a pleasure assisting you – I am hoping we don’t need to go through another fight. We’re here if you need us.

    Stephen JessupFeb 17, 2017  #2

  • Thank you for your newsletter. Again, it lets me know how fortunate I am to have found you and Steve Jessup to help me fight the “dynamic duo of denied claims”: The Hartford and “any occupation” definition of disability.

    I will call my Primary physician today to schedule an appointment to update my pain and limitations into his records. I pray it is not too late as a new claims adjuster is presently reviewing my case (for the last 6 months!).

    Sharpen your pencil, Steve J. I hope I don’t need you!

    Todd H.Feb 15, 2017  #1

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