Don't Get Boxed In On A Medical Form

If you ever needed some proof that disability insurance companies are fully invested in the idea of not paying benefits, no matter what, read Miles v. Principal Life, 2013 WL 3197996, a decision handed down by the 2nd Circuit Court of Appeals in late June.

Among other “missteps”, Principal totally ignored the expertise of its own examining physicians and demanded objective proof of the claimant’s tinnitus, which even their own doctors said was not possible. Principal denied the claim because Mr. Miles couldn’t provide proof of a condition which Principal’s own doctors said was not objectively provable.

The opinion contained additional important points on matters which we have commented in other posts. One was the common sense adoption by the Court that a claimant’s long work history enhances credibility. Statements of this nature are beginning to find their way into opinions as a telling point when proof of the claim is subjective and credibility is a major issue.

Another important point is that claims cannot be rejected just because they are based on subjective complaints of pain. The Court reaffirmed its holding in Connors v. Conn. Gen. Life Ins. Co, 272 F. 3rd 127, 136 (2nd Cir. 2001), that it is arbitrary and capricious to disregard evidence of pain because it is subjective. In such cases, the Court implied, credibility is an issue and the insurer must enunciate why a claimant is not to be believed.

We also cannot stress too forcefully the dangers of treating doctors limiting themselves to reports of their patient’s condition to a form provided by an insurance company. Insurance companies are not in the business of paying claims. Physicians must understand that the forms insurers provide to a claimant’s doctor are designed to limit the report to the barest details so as to make the patient’s claim appear skimpy and suspect.

Many busy physicians conform their answers to the information specifically asked for in the form and do not add information not specifically asked for. This can play right into the disability insurer’s hands. Disability claims not only have to prove their illness or injury, but also why that illness or injury prevents them from doing the work they were insured for.

Even if the doctor is careful and adds notes to amplify the limited space available on the form so as to be more accurate and forthcoming, the insurance company may just ignore this additional information, as it did in the Miles case. Insurers will stick to the form box answers in coming to a decision if it is in their best interest to do so.

Medical answer boxes on disability insurance forms are convenient for physicians but can devastate a patient’s claim if the doctor fails to elucidate when a limiting form box answer is incomplete.


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