Disability Claims Reviewer’s Investigation

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Jeffrey Johnson is a legal writer with a focus on personal injury. He has worked on personal injury and sovereign immunity litigation in addition to experience in family, estate, and criminal law. He earned a J.D. from the University of Baltimore and has worked in legal offices and non-profits in Maryland, Texas, and North Carolina. He has also earned an MFA in screenwriting from Chapman Univer...

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UPDATED: Feb 9, 2020

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Your claims reviewer may be calling and questioning you when he or she investigates your long term disability income benefit claim. You should know all the things a claims reviewer might do to investigate your claim. Initially your claims reviewer is likely to request your medical records from the treating physicians that you have identified on your initial claim forms.

Some of the investigative techniques they may use are:

Background Investigations

This type of investigation may include the following:

  • Interviewing your neighbors
  • Obtaining your employment records
  • Obtaining any records relevant to a Social Security claim or a Workers Compensation claim filed by you.

As a practical matter, there is little you can do in regard to intrusive investigative techniques since, more often than not, you are unaware you are even the subject of inquiry. Moreover, most policies state that to collect you must cooperate in regard to the investigation of your claim. However, limits do exist with regard to the scope of investigation, and the claims reviewer is not empowered to unduly harass or invade your privacy. If you have an issue in this regard, talk to an attorney.

Medical Examinations

To validate your claim, most disability income insurance policies expressly reserve the right of the insurer to conduct what are often called independent medical examinations (IME). Read your policy to determine if you are required to submit to an IME. (If you have misplaced your policy, ask the claims reviewer for a copy.)

IMEs are anything but independent since the retained doctor is chosen and paid by the insurance company and probably derives a substantial portion of his income from conducting these types of examinations. Furthermore, if the doctor is at all biased in his or her approach to these exams, the bias will likely be in favor of the insurance company. So much for independent.

If you are required to undergo such an exam and want to cooperate, you should advise the claims reviewer, in writing, that you intend to audio record the examination to ensure an accurate record of the examining doctor’s discussion with you. Also, get a statement, in advance, in writing, from the claims reviewer, that the retained doctor is aware of this arrangement. If the doctor refuses this arrangement, then you should confirm this in writing to the claims reviewer, appear for the exam and then immediately confirm in writing to the claims reviewer the substance of your discussion with the doctor.

Refusal to consent to the requested evaluation–if there is no reasonable basis for your refusal–may result in a legitimate denial of your claim if the insurance company can show that it is simply using the exam in an honest attempt to clarify existing unclear medical information necessary to determine the true nature and extent of your disability

Watch out here. A claims reviewer’s request for an IME is a red flag to a potential problem in your claim. At this point it may be wise to contact a lawyer who has experience with disability insurance claims and ERISA.

Surveillance Tactics

Undercover surveillance techniques is another tool used by the claims reviewer. There are limitations to what the insurance company can do. For example, while it may be permissible to videotape you while you are out in public or even in your own yard, surreptitious taping of you inside your own home would likely constitute invasion of privacy. The claims reviewer should let you know that surveillance may be used during the initial claims investigation or even after benefits are approved. If you think the insurance company is engaging in improper activity in this area, consult an attorney experienced in insurance company issues.

Medical, Employment and Financial Records Release

Beware of such a request. The claims reviewer may ask you to sign an Authorization for Release of Confidential Information, instead of an Authorization for Release of Medical Information. When given to you to sign, the implication may be that the authorization is needed to obtain necessary medical history related to your claim. But the authorization wording may be broader than that, allowing for disclosure of school or employment records or confidential financial information. Read the authorization carefully. Do not sign it unless the claims reviewer can explain how such additional information is relevant to your claim.

Phone or Personal Interviews

The claims reviewer may suggest a phone interview or a face-to-face meeting with a field investigator. Whatever the circumstances may be, it’s wise to record the proceeding either by audio or video tape. If the claims reviewer will not agree to a recorded interview, you should confirm the refusal in writing and offer to submit to a written interview from the claims reviewer. If the reviewer declines, but you wish to cooperate, submit a dated, written summary of the interview to the claims reviewer immediately after its completion.

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