It's actually quite possible that your disability case will be determined by something a doctor you've never even met has to say. IMEs generally don't meet or examine the people who they're asked to assess. Instead, they review the files you've sent to the insurance company and, once in a blue moon, speak to your treating physicians. It's no wonder why they do it. It's difficult to get doctors and patients together over great distances, it lessens the possibility of a plaintiff unduly affecting or trying to embellish results (which they can tell), and it depersonalizes the process so they don't have to feel bad about denying benefits to people they like and feel sorry for.
But in this case they go beyond that. They don't even contact the treating physicians, those who have medical knowledge and know the facts of the case the best. Of course they're going to deny benefits if all they're doing is reading a piece of paper. They can come up with hundreds of excuses to discredit written words because words can't argue back like another doctor can. Not contacting treating physicians, or trying to contact them when they know they'll be unavailable (i.e. around lunchtime), simply makes the IME's job easier and it's no shock that it's incredibly common in this industry of the underhanded.
In the case of Schully v. Continental Casualty Company this was exactly the case. Click the link to read a news blurb followed by a press release and the entire opinion on the case involving IMEs and their diagnoses by proxy .
The University Disability Consortium (UDC) gets hired by insurance companies to independently review medical claims. They advertise that their service will most likely result in "improved denial and closure rates at a reduced cost."
Translated: "If you hire us, we will deny claims to save you money."
And they'll do it in a plethora of ways. In the case of Velikanov vs. Union Security Insurance, UDC's Dr. Brian Mercer used the "close-enough" method. As in he addressed a condition that the claimant didn't have, but hey, the condition he wrote about and the condition the claimant had (two different types of cysts) were "close enough" that they could be misconstrued by anyone without a medical degree. Either he's not doing his job right (misreading files) or he IS doing his job right (finding ways to deny legitimate claims).
The judge basically threw out Dr. Mercer's opinions because he found them to be "inherently bias." I have a feeling that that term could be applied to most if not all insurance docs but as of now it seems their pseudo-medical opinions are still generally accepted in the courtroom. Read more on Velikanov vs. Union Security and see how UDC gets scolded.
Another good bit of news for those seeking disability benefits. In the recent case of Toth v. INA a judge granted the plaintiffs motion for summary judgment based on the fact that CIGNA's medical team, made up of Drs. Dan Gerstenblitt and Paul Seiferth, didn't offer any evidence to back up their opinions of non-disability other than pointing out that the plaintiff's treating physicians lacked objective evidence. Maybe the CIGNA doctors should leave the lawyering to the lawyers.
In a lot of these cases one of the major problems is that many debilitating disorders and syndromes are beyond current means of objective testing. The insurance docs, such as CIGNA's, use this fact to claim that there is no evidence of disability, when in reality the level of evidence they want is unattainable with current medical technology.
In this case, the judge decided that this wasn't good enough for CIGNA to deny benefits and that the overwhelming record from the treating physicians was more than enough to justify benefits despite that much of it was based on "self-reports" from the plaintiff. This a great ruling in that it basically recognizes the impossibility of attaining a certain level of proof that insurance claim as necessary for granting benefits. Read more, including entire opinion on Toth v. INA, on how treating physicians opinions can hold more weight than insurance doctors.
Another case in which an insurance doctor rides the line between ethical an unethical. A doctor for the infamous University Disability Consortium (UDC), Dr. Beth Aaronson, reviewed a file for a claimant who suffered from a left arm disability, temporal lobe epilepsy, protein S deficiency, and deep vein thrombosis.
I suppose it's possible that she missed the last three on that list, which would be grossly negligent, but I trust in Dr. Aaronson's skills and find it much more likely that she ignored them on purpose because she either couldn't contend against them or couldn't bring herself to come up the bogus medical opinion it would take to discount the evidence. Either way, she only addressed the left arm disability. I guess if they can't use whack medicine to discount a claim they just ignore it, great strategy!
A recent suit filed by Sedgwick Claims Management Services against blogger Robert Delsman has been thrown out by Northern California District Judge.
The blogger actually represented himself in this case and filed the motion that the court construed as a motion to dismiss. While it wasn't exactly eloquent or artful it did the trick and showed that Sedgwick was using the lawsuit to intimidate him and infringe on his freedom of speech. A California law, known as the SLAPP Act, protects citizens from intimidation through litigation brought by private interests.
Here's a case that highlights the insurance company's contradictory policies. On the one hand, they're doing their darndest to deny your claim while on the other hand they're paying for a lawyer to prove to Social Security that you're as disabled as could be.
Most LTD plans have a clause that says LTD payments from the insurer can be offset by Social Security disabilit benefits and they require you to apply for it if you're granted benefits. It's a good idea to know all about your policy. Does it have something like this in it? If it does, expect a similar battle.
A recent case out of the USDC of Sourthern New York was won by plaintiff Tracy Solomon. Ms. Solomon was granted LTD benefits from her plan with MetLife.
One of the highlights of the case was the relationship of the medical reviewer with MetLife. Dr. Amy Hopkins was hired my MetLife to be an independent medical reviewer and to determine if Ms. Solomon was disabled. The decision to terminate benefits was based largely on Dr. Hopkins' report that Solomon was able to work. Solomon contested the validity of Hopkins as an independent medical reviewer due to her close ties with MetLife. Upon further review it was found that Dr. Hopkins earned well over half of her income from doing independent medical work for MetLife. The judge determined that this was a relationship that went beyond what is acceptable for a reviewer to be regarded as "independent."
The inherent bias of having to determine disability payments from your employer casts doubt on the validity of Dr. Hopkins' opinion. In the cutthroat world of insurance, companies favor those doctors who give them the best chance at legitimate denial. With such a vested interest in maintaining a relationship with MetLife, her largest beneficiary, the possibility of bias and the solid medical evidence that contradicts Dr. Hopkins' opinion is enough to determine that her report is flawed. This judge set it right, let's hope others follow suit and insurance companies learn to use legitimately independent doctors. Here's the entire Solomon v. MetLife opinion .
Here's a case involving MetLife's group disability plan for Eastman Kodak. The plaintiff suffered from chronic fatigue syndrome (CFS) and was initially given full benefits.
MetLife decided to review the case and, well, they didn't do a very good job of it. The doctors they had evaluate the plaintiff didn't really use any evidence and when they did, they did so selectively.
There is no one test that can be used for CFS because it is an amalgam of several symptoms rather than a disease. So all the tests that the plaintiff's primary care physician said pointed to CFS, MetLife's docs said they didn't, claiming that there was not objective proof of the condition. And when they were asked repeatedly what the plaintiff could do to provide objective proof (remember there is no test for CFS) the question was ignored.
Brilliant. The insurance companies want a level of proof that's not possible. A definitive result from a non-existent CFS test.
The opinion, linked above, is quite a good read. The judge really goes after MetLife on some of its self-contradictions and gets after a MetLife doc's report saying it "can be characterized as shoddy and incomplete."
The whole point is that insurance companies have to be responsive and specific when they deny a claim. They have to answer the question of why the claim was denied and also explain what they would need to accept it. If they don't, something's up.
Looks like Suze Orman is finding herself in a bit of hot water out in California. She's being sued for "civil fraud, conspiracy and breach of fiduciary duty" for an insurance deal she set up in 1999. She was the insured's financial advisor AND insurance salesperson, talk about conflict of interest. Check out the article, linked above, and you'll see what I mean.
It's not all negative though. This provides an important lesson to those purchasing insurance plans. The fancy brochure used to sell this policy said one thing and the fine print said another - typical stuff. The sales people don't even know what they're selling. Always make sure to read your policy thoroughly, especially the fine print, and if need be, get an attorney to help you do so.
At first blush, you may feel the title is outrageous. However, upon reading the book, you will realize that Glass has probably understated the mass deception that results from employers and insurance companies “stealing” hundreds of millions of dollars each year in disability insurance benefits which should have gone into the pockets of disabled employees and their families.
Nancy Cavey has a great discussion about disability insurance companies spying on you and videotaping your activities. There are some real clues to know when this will happen and Nancy discusses this here.
If the activity in our office is any reflection of what's going on nationally, the disability insurance companies seem to be ratcheting up the screws recently. We've seen everything from sudden terminations of long-running claims to companies denying claims without any appropriate medical review (or anything close). Video surveillance seems to be on the increase as well.
I explain the rip off of group disability insurance policies issued through employers and governed by ERISA in my book, Robbery Without a Gun, Why Your Employer's Long-Term Disability Insurance Policy May be a Sham.. A major individual disability insurance company (i.e. they don't sell these crappy, worthless group policies) just placed a major order for my book (probably to give to its sales agents.)
Insurance companies routinely require disability claimants to apply for social security benefits, even though they know that the vast majority won't qualify.
Now, a federal jury has found Unum guilty of fraud in some cases where Unum has required the claimant to go through this time and energy wasting process.
Tampa long term disability attorney Nancy Cavey has an excelent post over at her website about what to do when the disability insurance attorney wants to come pay you a visit. As Nancy points out, this is almost never good news.
Beware, this "friendly visit" probably means that they already have you on video. These companies are tricky.
Nancy Cavey is the best long term disability attorney in Florida. Read her post here.
When employers allow insurance companies to put a "we have discretion to determine" benefits clause in a group long term disability policy, they are doing their employees a grave disservice. Only crappy disability plans have this language, which tilts the playing field mightily in favor of the insurance company.
The Fourth Circuit Court of Appeals dealt a huge blow to Prudential Insurance Company of America yesterday in an ERISA long-term disability case.
The case is Patricia Woods vs. Prudential Insurance Company of America.
The big issue in these cases is whether a federal judge and look at a claim denial "all over again" or whether he has to grant deference to the insurance company denying the claim.
In order to grant deference, the disability plan must have certain magic language in it "granting discretion."
The Court of Appeals ruled that standard language that Prudential uses in its plans does not grant discretion and that claims must be reviewed de novo.
This could effect thousands of Prudential group long term disability insurance policies and is a major victory for claimants.
Some of the major disability insurance carriers will stop at nothing to keep sticking it to claimants.
Its tax time and the insurance companies are sending 1099's to those with whom it entered settlements last year.
At least one company is telling the IRS, via the 1099's that the settlements are taxable benefits, even if the benefit itself was not taxable! If you are getting disability benefits and you paid the premium for the policy, then any benefit you get is non-taxable. That's straight up federal tax law.
A major company is taking the position that "yes, you are right but since this is a settlement we are going to report it to the IRS as taxable."
Pure, outright fraud on the part of this company. The disabled insured is left paying more attorney and CPA bills to straighten out the mess...all because this major insurance company is either stupid as all get out or mean as the devil.
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