What Does a Physician Consultant Do in a Disability Insurance Claim?

Mar 5, 2020 | Blog |

At some point during a long-term disability insurance claim, the insurance company may ask a physician consultant to evaluate your case and medical records. When you get this notice, it can lead to worries that your LTD benefits are in danger. You may also wonder how this doctor who has never met you or examined you in person can provide a valid assessment of your claim.

In this article, we’ll discuss the “peer review” process used by physician consultants and explain whether you should be worried when one gets involved in your claim. Keep reading to learn more.

What Does a Consulting Physician Do During a Peer Review?

As part of their investigation of your claim, a disability insurance company can consult with physicians and other medical professionals about your case. Sometimes, an adjuster will schedule an independent medical examination (IME), where a doctor of the company’s choosing will review your medical records, perform an exam, and issue a report.

Other times, the insurance company will decide to simply have a doctor or nurse review your medical records and provide an assessment. This is called a peer review or physician consultant review.

A peer review typically involves a series of steps:

  1. The adjuster selects a physician consultant, who is either an independent contractor or works directly for the insurance company.
  2. The physician consultant gets copies of your medical records and gathers the information in your long-term disability insurance file.
  3. After reviewing all the documents, the physician consultant may contact your doctors and speak with them about your conditions.
  4. The physician consultant will write a report that summarizes your medical conditions and give an opinion about your ability to work.

This report will become part of your LTD evidentiary file, and the adjuster can consider it as they decide whether to grant or deny your claim.

RELATED: What Is a Functional Capacity Evaluation?

A Peer Review May Also Involve Surveillance

What some people don’t realize is that surveillance and a physician consultant’s review often go hand in hand. The adjuster will argue that surveillance footage, especially video, can help a peer review doctor assess your movements and abilities. However, a few videos recorded in public places can’t fully demonstrate your abilities and limitations.

While you can’t stop the insurance company’s investigators from recording your public activities, you can take steps to protect yourself. First, never “tough it out” and attempt activities that are outside your restrictions. Second, if an investigator or another stranger enters your property, politely ask them to leave. Also, you should know that an investigator cannot film you in areas where you have a reasonable expectation of privacy (like your bedroom or a bathroom). If you feel harassed or threatened by an investigator’s actions, immediately call your disability insurance lawyer and the police.

RELATED: Can Your Social Media Feed Hurt Your Disability Insurance Claim?

Do Physician Consultants Always Side With the Insurance Company?

Under ERISA §503, insurance companies must evaluate claims “in a manner designed to ensure the independence and impartiality of the persons involved in making the decision.” So, the insurance company cannot hire, compensate, or fire a physician consultant because their report favors either side in the claim. At least, that’s how it should work in theory; in practice, things are rarely so black and white.

To be clear, a physician consultant can side with you and your doctors, and this does happen from time to time. However, peer review reports are more likely to align with the insurance company’s interests, not yours.

Physician consultants are well-compensated for their work, and some are employed directly by the insurance company. So, while the consulting physician may claim to be “neutral” and even work to keep up the appearance of being impartial, they often have behind-the-scenes allegiances and an overall perspective that favors the insurer.

How Do You Fight a Negative Peer Review Report?

If you get an unfavorable decision from a physician consultant, you should consult a disability insurance lawyer. Insurance adjusters often rely on unfavorable peer review reports when they deny or terminate benefits. However, you can appeal a denial or termination.

During an initial ERISA appeal, you’ll need to carefully review the insurance company’s file, supplement the evidence, and demonstrate that your conditions are disabling. Succeeding in this process requires attention to detail, a strong understanding of the medical and legal issues that impact your claim, and aggressive tactics.

Even if you’re a highly educated professional, it’s difficult to navigate an ERISA appeal without help from an experienced attorney. At Bryant Legal Group, we focus our practice on complex disability insurance claims, and we have built a high-end reputation based on our practical, results-driven approach.

Bryant Legal Group: Fighting for People With Disabilities in Illinois

As one of Illinois’ premier disability insurance practices, we can help you regain your control and understand your legal options. If you have questions about a consulting physician’s peer review, schedule your no-risk initial consultation by calling us at (312) 561-3010 or filling out our quick online contact form.

Resources

29 CFR §2560.503-1 (2017). Retrieved from https://www.law.cornell.edu/cfr/text/29/2560.503-1

The content provided here is for informational purposes only and should not be construed as legal advice on any subject.

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