Resource Center

Professionals are often surprised to learn that even though they’ve been paying premiums for years for a disability insurance policy from a respected insurance company, when the time comes to file a claim for benefits, they face a daunting uphill battle to recover a single dime. It seems reasonable to expect the insurance company to honor its obligation once you’ve provided basic medical evidence of your disability. But that is rarely the case.

The medical evidence requested often requires months of testing, evaluation, and expert opinions and observations. Documentation must be meticulous. And then just when it seems like the requirements are satisfied, the insurance company will often obtain one statement that destroys everything.  

That statement comes from your doctor. Insurance companies use a variety of misleading tactics that essentially trick physicians into saying something that provides grounds to deny a claim for benefits. It is important for claimants and their physicians to be aware of these tactics and on guard against statements that can be misinterpreted or taken out of context to justify denying or limiting benefits under a disability insurance policy. At Seltzer & Associates, we have dedicated our practice to helping professionals in Pennsylvania recover the full benefits from their private disability insurance policies, and we’ve seen the underhanded strategies insurance companies often employ to prevent policyholders from receiving the resources they need when a disability prevents them from working. We are ready to help at all stages of the claims process, from filing an initial claim to appealing a termination or denial. When you understand the challenges that lie ahead, you can be better prepared to face them.

A Claimant’s Treating Physician is the Insurance Company’s Biggest Target

When you are pursuing a claim for long-term disability benefits, there are hundreds of thousands of dollars at stake, and your insurance company is well aware of it. To you, these are the funds you were promised when you contracted for disability insurance. To the insurance company, it’s an obligation to be avoided at all costs.

The insurer will require medical evidence of all types from various sources. But they know that if your claim ever needs to be decided in court, the most persuasive evidence will come from the doctor who has been treating you all along. That physician is familiar with the extent of your disabling condition and the impact it is having on your life.

So, insurance companies often target these physicians by using physicians on their own payroll. They often call for a seemingly informal and quick “collaboration” call. While the insurance company physician pretends to call to better understand the claimant’s condition and limitations, in reality the call is designed to uncover any information that can be used to provide “reasonable” grounds to deny the claim.

Common Tactics to Be Aware of In Peer-to-Peer Contact

If a disability insurance claimant is working with an experienced Pennsylvania disability insurance attorney, it can be helpful for the claimant’s treating physician to speak with the attorney about the potential tricks and conversational traps that could be used during the course of the claims process. Below we address some of the most common “trick” approaches we’ve seen over the years, but insurers are devising new tactics all the time. 

Asking Ambiguous Questions

Often, an insurance company physician will ask an extremely broad question when what they need is very focused information. For instance, if the claimant has an “own occupation” policy that is supposed to provide benefits when a professional is unable to continue with an established practice, the insurance company needs only to establish that the claimant is not in a condition to work in their current profession. Yet the insurance company physician might ask simply whether the claimant is able to “work.” 

The claimant’s doctor might answer “yes” initially, thinking that the claimant may be able to do some kind of other work on a part-time basis. By asking vague questions, insurance physicians often obtain answers that can be twisted to their purposes.

Gaining Admissions About Activities of Daily Living 

Physicians employed by insurance companies often try to find out whether a claimant is able to undertake aspects of daily living so that they can use this information as justification to assert that the claimant can perform certain types of sedentary work and that they therefore do not qualify for benefits. For instance, an insurance physician might try to find out whether the claimant drives to appointments. 

The claimant might be able to make a five-minute drive to the doctor’s office once a week, and that might be the only time they leave the house. But the insurance company can twist that into evidence that a claimant is fit to work.

Challenging the Diagnosis or Treatment

Insurance companies will often have peer-to-peer calls conducted by physicians who are knowledgeable but who practice in a specialty that is completely unrelated to the condition that is causing the claimant’s disability. The insurance physician will then dispute the grounds for the treating physician’s diagnosis or assert that treatment is inappropriate or not adequate to meet the requirements under the policy.

Skewing the Perspective

Another way insurance companies sabotage peer-to-peer contact is by providing their own physician with only selected records about the claimant’s condition. In this way, the insurance physician is not given inaccurate information, but rather incomplete information that can prejudice their assessment and skew their perspective of the entire case.

Following Up on the Attack

After a peer-to-peer interview, insurance companies often engage in additional shady practices to follow up on the assault on the claimant’s treating physician and make it even more difficult to overcome the attack.

They will usually send a “summary” of the interview to the claimant’s treating physician for review and approval. This summary often omits critical information or contains flat-out errors. The insurance will often pressure the treating physician to review and sign quickly, so the treating physician does not notice the errors or omissions. The statement may be provided at the end of the day or just before a holiday when the treating physician is trying to tie up loose ends. Or the insurance company may impose on the treating physician by contacting the office at the busiest time of day to catch the physician off guard and in a hurry.

In the summary or during the peer-to-peer interview, the insurance company representative may try to slip in definitions that differ from those contained in the disability insurance policy. For instance, the term “disability” can be defined in many ways. For the purposes of the disability insurance claim, what matters is the definition in the policy. But the insurance company may encourage the treating physician to use a different definition. This can either make it more difficult for the claimant to qualify or can introduce uncertainty or give the appearance of inconsistency, making the doctor’s opinion less reliable as evidence.

Preventing Problems

The easiest way to prevent some of the problems caused by these underhanded tactics—and save your treating physician from stress and inconvenience—is to have your disability insurance attorney consult briefly with your physician. If you do not yet have an attorney, some steps that can protect your physician and your claim include:

• Informing the insurance company that any peer reviews, peer-to-peer interviews, or other communications with your physicians must be scheduled in advance. This provides time for preparation and avoids some of the time pressures that often lead to harmful statements.
• Having all communications with your physicians be conducted in writing. When questions and answers are provided in writing, an attorney can review answers to watch for underhanded tactics or potential contractual ambiguities.
• Ensuring that your treating physician understands the definitions that are crucial to your claim, including the definition of disability that makes you eligible for benefits and what that definition encompasses.

When you work with an experienced Pennsylvania disability insurance attorney, you have an ally who understands many of the medical issues you are dealing with, as well as the legal issues that affect your rights to receive benefits under your policy. Your attorney can serve as a valuable resource to answer your questions as well as those posed by your physician. Allowing your attorney to serve as an intermediary can make life less stressful and smooth the recovery process.

Don’t Let the Insurance Company Sabotage Your Medical Support System

Your treating physician should be one of the strongest allies in your recovery battle. It is important to do what you can to protect this ally and maintain the effectiveness of their testimony in support of your claim.

The insurance company will do whatever it can to undermine this relationship and the assistance provided by your doctor. What you see as the fulfillment of a contractual obligation and the provision of support for your future is seen by the insurance company as an expense that they want to avoid. Even when insurance company representatives act friendly and sympathetic, it is important to remember that their aim is the complete opposite of your own. They cannot be trusted.

Knowing some of the tactics they may use against you can help protect you and your claim. But many professionals find it most effective to work with a knowledgeable private disability insurance attorney from the very start of the claims process to avoid unnecessary delays. At Seltzer & Associates, we know how to appeal claim denials through both internal processes and litigation. However, when we can work to overcome the insurance company hurdles from the outset, it can allow a claimant to start receiving benefits much more quickly.  

Schedule a Free Consultation with Seltzer & Associates

Disability insurance is a complex topic, and claims are fiercely contested because the stakes are so high. When you work with a dedicated legal ally, you can allow your attorney to manage the claim details while you focus on your physical, mental, and emotional recovery.

The team at Seltzer & Associates has focused on resolving disability insurance difficulties for decades. We invite you to schedule a complimentary consultation to discuss how we may assist with your case. Just call us at 888-699-4222 or contact us online to get started.