Medical treatment and history is one of the most critical pieces of evidence that disability Insurance companies rely upon for deciding claims for disability insurance benefits. The strength of these medical records is critical for the disability insurance company to assess whether a claimant is truly disabled and entitled to benefits under the terms of their policy.
Disability insurance companies also look at your medical records for potential reasons to deny claims. While many claimants understand the importance of a diagnosis, you may underestimate how the consistency, type, and frequency of treatment can either strengthen—or unintentionally weaken—your claim.
Medical treatment and the attendant records are the foundation of your disability insurance claim. The disability insurance claims adjuster will look for a few key elements when evaluating your claim:
- The existence and severity of your condition
- Often described by symptoms’ frequency, intensity, duration or severity
- The functional limitations resulting from your condition.
- Often noted by specific things which should not or cannot be performed.
- The credibility of your reports of pain, fatigue, or cognitive impairment
- Often supported by treating doctor.
- Your efforts to improve or manage your condition.
Your medical records must show clear evidence of a consistent, well-documented treatment plan and demonstrate your compliance with professional advice. Conversely, gaps in care or inconsistent adherence to treatment will raise red flags for insurers, suggesting that the condition is not as disabling as claimed—or not disabling at all.
Claims adjusters are looking for a consistent pattern of medical treatment. Regular visits to specialists, ongoing therapy, and prescribed medication use all help establish the seriousness of your condition.
It will be important for your claim for records to prove you attend doctor appointments, adheres to prescribed treatments, and communicate regularly with healthcare providers. Depending upon your condition, even a short gap in treatment will be reason for an adjuster to question your claim.
Your Claim Success Depends Upon Objective Medical Evidence
Subjective symptoms like pain and fatigue are common in disability cases and always raise a red flag. Disability attorney Jason Newfield is skilled in identifying the types of diagnostic tests used to support what would otherwise be subjective. His national network of medical experts and specialists allows his clients to receive gold-standard tests for conditions like Fibromyalgia and Epstein Barr. He knows what the insurance company adjusters are looking for and works with treating doctors to ensure medical evidence is robust to support the claims.
The medical treatment process often generates this evidence over time but it needs to be present before a claim is filed to create a well-prepared claim. Regular care allows treating physicians to build a comprehensive record of the claimant’s impairments and limitations, which can be used to directly tie medical findings to an inability to work.
Who’s Your Doctor and Why You Should See a Specialist
Seeing specialists—such as rheumatologists, neurologists, oncologists, or psychiatrists—enhances a long term disability claim by aligning your condition with expert medical care. Even if your internist is known in your community as a skilled practitioner with your condition, if you aren’t being treated by a specialist, the insurance company will question how serious your disability really is.
Being treated by a specialist adds another layer of credibility to your claim. This may be unfair or even unnecessary, but the insurance company is looking for flaws in your claim and you don’t want to hand them an easy reason for a denial.
In cases of mental illness or chronic pain, ongoing therapy or pain management programs can also serve as important proof that the claimant is seeking appropriate, professional-level care to manage their condition.
Jason Newfield starts his detailed preparation of the medical record portion of claims with the idea that the insurance claims adjuster knows nothing about your condition, the medical doctor or nurse reviewing your claims file will know nothing about your condition and the inclusion of medical journals may be necessary to educate all involved so they are more likely to make an informed decision.
If that sounds like too much, it may be – but it’s necessary to protect the claim and Jason Newfield does it for a reason.
Documentation of Treatment Response Shows Effort
Insurance companies want to see that claimants are actively working toward recovery or stabilization. Even if treatment has not improved your condition, documented efforts—such as trying different medications or physical therapy—help demonstrate that you’re actively engaged in trying to help yourself get better.
Insurance adjusters often accuse claimants of malingering, not trying to get to work and not trying to get better. This is insulting, as most claimants would do almost anything to get their life and their health back. However, it happens, and the claim needs to be supported by proof of any efforts and any medical treatment.
Can Medical Treatment Undermine a Long Term Disability Claim?
Not everyone’s treatment history helps a claim. In some cases, certain patterns—or lack thereof—can give insurers ammunition to challenge a disability.
Gaps in Treatment Raise Questions Significant lapses in medical care can suggest to an insurer that the condition has improved or isn’t severe. While there may be legitimate reasons for gaps—such as financial constraints, lack of transportation, or mental health struggles—insurers may not always interpret them sympathetically.
If you do have a break in treatment, it’s important to be able to document the reasons for your physician and the insurance company. Disability attorney Jason Newfield has successfully represented claimants with gaps in medical care, but it adds another layer of challenge to your claim.
Failure to Follow Recommended Treatment Plans Insurance companies will scrutinize whether you’re following your doctor’s advice. Missing appointments, refusing treatment, or failing to take prescribed medications will undermine your claim. The rationale is simple: if you’re not following through on treatment, the insurer may argue that your condition could improve if only you complied with medical advice.
Here’s the problem: claimants have the right to refuse treatments that are overly invasive, experimental, or carry significant side effects. There are many cases where insurance companies decide your treatment would improve if you underwent certain types of care. Let’s say a dentist has carpal tunnel syndrome. In some instances, surgery doesn’t help and can make their condition worse. However, the insurance company told the dentist that if they don’t undertake the prescribed surgery, they will stop paying the claim. Newfield Law Group has handled such claims, fighting back against insurance companies and winning cases.
Hate Taking Medication or Going to Doctors?
We all know people who don’t go to the doctor for decades and live well. We also know people who become affected with serious illness and decide they know better and aren’t going to undergo treatment or take medicine. Not going to the doctor for treatment and failing to comply with medical recommendations will put your disability claim at serious risk.
Some claimants manage their condition primarily through lifestyle changes or alternative treatments. While these methods may be beneficial, they often lack the documentation and clinical support insurers require. Without a treating physician’s consistent involvement, the insurer may consider the impairment insufficiently severe to warrant disability benefits.
What About Contradictory Medical Records?
Jason Newfield works closely with his clients’ physicians, as they aren’t – nor should they be – Long Term Disability Insurance Attorneys. They don’t know that a conflicting diagnoses, vague symptom descriptions, or notes suggesting symptom exaggeration or the presence of anxiety/depression—can significantly damage your case.
An array of issues is seen with medical support. While many doctors want to support the claim, they may not be strong in how to articulate the support. Others, often surgeons, will not support claims post surgery – believing that the mission was accomplished, while often ignoring the residual functional deficits that remain.
If your medical record, physician, or diagnosis is tenuous, your long term disability insurance claim may be in jeopardy. Contact Jason Newfield for a complimentary telephone evaluation of your situation.
