We have come to learn that there is no shortage of tactics insurers will use to deny claims — as boosting their bottom line is often a top priority.  As best we can tell, they frequently take advantage of those who do not understand the terms of their policy, as well as those who are sick, those who are elderly, and those who are unable to fight back.  Injustice permeates the health related insurance world. Often, the medical records of a person making a claim for disability benefits will be referred to “independent medical reviewers” for opinions on the nature and extent of disability.  It should come as no surprise that these reviews, more often than not, support a denial of benefits.

What is meant by an independent medical review? An independent medical review is often arranged by the insurance company during a health insurance claim so that the insurer will have some evidence to offset or critique what treating physicians say about their patient.  The problem is, these reviewers are usually anything but independent, and most likely spend the better part of their work day writing opinions for insurers that support claim denials.  And, they can make a healthy living doing this.  Knowing “where their bread is buttered” so to speak, these doctors can be relied upon to give the insurance companies ammunition to repeatedly support claim denials.

So what can be done to challenge these unfair denials and unfair practices? Arm yourself with knowledge! The more you understand about your policy, and the benefits to which you are entitled under your plan, the more comfortable you will feel in pursuing your claim and challenging any obstacles that may appear.

First, if your claim is denied, understand that an insurance denial is not the final word. For advice on the appeal process, see our post on Everyday Health Insurance Challenges and What You Can Do To Overcome Them. Furthermore, if you feel that your “independent review” is not so independent, don’t ignore this! It is possible for you to challenge your insurance company’s decision, and here’s how:

  • Talk to your doctor.  Show the reviewer’s report to your doctor and ask him or her to point out the defects or inaccuracies of the review opinion; and to put that information in writing for you to present to the insurance company.
  • Write to your insurance company. Write a letter telling your insurance company why you think your independent review was biased. Ask your insurer to provide you with the qualifications, specialty, and licensing information for their review doctors. Also, we encourage you to conduct some independent research online. See if you can determine the extent to which the doctor actually practices medicine, versus performing work for insurance companies.
  • Contact the DOI (Department of Insurance) or DOL (Department of Labor). Send a letter to the DOI or DOL explaining why you think your independent review was biased.
  • Include this information in an appeal letter. When appealing an insurance denial, include information about your medical review. If the reviewing doctor was not qualified to make a decision about your health, explain why.
  • Contact an attorney for help. It’s not always feasible for people to challenge insurance issues on their own, especially when dealing with a serious illness. In this case, it might be helpful to contact a reputable attorney for support. Many attorneys work on a contingency fee basis, meaning that they will not collect a fee from you unless your claim is paid.

It’s frustrating, but ultimately an insurance company can use whoever they want for a medical review.  Only if the matter goes to court, and the file contains sufficient evidence to convince the judge that the review doctors were biased or unqualified, will the insurance company suffer any consequences of their conduct.  Since that doesn’t happen very often, they persist in using same review doctors.

At Kantor & Kantor, we work diligently to challenge these types of unfair practices. We spend every working day fighting on behalf of our clients so that they can access the insurance benefits to which they are entitled. If you have been denied benefits for your long term disability claim, please do not hesitate to reach out to Kantor & Kantor at (800) 446-7529 for a no cost consultation.

We understand, and we can help.