Just when Jason Newfield thought he couldn’t be surprised by anything the disability insurance companies did to claimants, along came another doctor, or maybe alleged doctor, wrongfully stating that a person with severe orthopedic conditions limiting her use of her hands in oral surgery was perfectly fine and could go back to work.
There are situations where cases are not black and white, but this was not one of them. An equity partner in a successful practice, the claimant had suffered from pain in her right hand as the result of the repetitive stress of performing oral surgery for decades. When she had a fall and instinctively put her right hand out to break the fall, she broke her wrist and damaged the hand further.
How is it possible that a disability claim for the inability to use a hand by an oral surgeon, compounded by fractures sustained in a fall, could be denied?
Part of the work Jason Newfield does when representing clients is obtaining and reviewing the claims file from the insurance company. This file is to contain all of the materials used by the insurance company and its various agents to come to the denial decision. This includes reports from employees of the insurance company, which can include doctors, nurses, claims adjusters and in-house occupational experts. It also includes the third-party administrators, who work for companies who are hired or owned outright by the insurance company with an eye to what they politely call “managing claims” or “containing costs.” There also might be investigative companies, conducting surveillance or other third party contacts.
In other words, there is an entire industry surrounding every insurance claim, owned by, or paid by the insurance company. It is in their best interest, whether they are employees or paid by a company hired by the insurance company, to find in the best interest of the insurance company. It’s not supposed to work that way, but it often does.
Next question: what kind of medical professionals work for an insurance company? They are generally not doctors or nurses who want to work with patients in a hospital or office setting. They often don’t ever meet claimants. For many, their days consist of reviewing paper records of individuals who have filed claims. Their perspective is totally different than the caring, dedicated medical professionals most of our clients work with.
In some cases, they are medical professionals who aren’t practicing anymore because they have lost their privileges to practice but are still qualified to review claims files based on their education and knowledge.
In many cases, they are medical professionals who are general practitioners. They aren’t blazing leaders in the field, racking up awards and publishing in medical journals. They’re not at the forefront of medical specialties. They may never set foot in a medical conference or attain board certification, which distinguishes doctors who are committed to the quality of care for their patients and to advancing their knowledge and expertise.
So, these are the medical professionals who turn to working for the insurance companies because it’s good steady work and they don’t have to deal with the challenges – and there are many – of working in a patient facing practice or a hospital or a medical school. Nothing wrong with that choice. But unfortunately, it impacts our clients’ claims.
The aforementioned oral surgeon enjoyed her work and her practice. She was not looking to get out of being an oral surgeon. But why was she denied her disability insurance benefits, both for her private or individual policy and her group ERISA disability insurance policy?
After reviewing her file, Jason Newfield learned that the doctor reviewing her claim had no experience in orthopedics. He also didn’t receive her entire file. This is something Mr. Newfield sees occur more than it should. Is there a slip up somewhere in the claims file review process, or did someone higher up in the claims administration determine the reviewing doctor didn’t need to see the complete set of MRI images of the oral surgeon’s injured hand? What other important documents did not make it to the review?
Jason has represented people in long term disability claims disputes who were denied their benefits by a non-practicing doctor where the person’s treating physician was a well published practicing and board certified expert in a high niche medical practice. The claim was denied by a generalist who was actually involved in a disciplinary action which had led him to work for an insurance company.
Upon receiving client’s claims files, Jason and his team dig deep into the reports, seeking more than why the claim was denied, but who denied it. Research is performed into the reviewing doctor, and any history of bias to explore. More often than one would wish, it turns out the person making the decision about the claim isn’t truly qualified to make that determination. If they are reviewing only a select portion of a claim file, the possibility of getting a fair review of the claim is even less.
Disability insurance matters are challenging for people who are not accustomed to dealing with huge insurance companies. For a free consultation with Jason Newfield, call the office or complete a contact form. There’s too much at stake to do this without the help of an experienced disability insurance attorney.
