Making Your Medical Records Work for You in Appealing Long-Term Disability Benefit Denials

October 21, 2009

Talk to your doctor, and make sure he writes it down!

Everyone who goes to the doctor is familiar with the routine of the doctor asking questions and making notes in a chart. For most of us, few people may look at those notes again, and they won't play a big role in our lives. For someone with a contested long-term disability denial, or a d health benefit claim, these records may be the key to succeeding in an administrative appeal of a benefit denial, or prevailing in a law suit to force the insurer to pay the benefit. A long-term disability benefit appeal or an appeal of a medical benefit denial can be much easier if the medical records support the claim.

The doctor's reason for creating the medical record is generally to provide a history of your condition and care so that doctor, and any future doctor or specialist, will be able to know what is going on. In a benefit appeal, the most important function of the medical records is to provide an objective, contemporaneous record of your impairments, either physical, psychologically or cognitively.

When most people get a denial letter from an insurance company, they think all they are going to need is a letter from their doctor stating that the doctor believes they are disabled. This rarely works. Insurance companies want to make their own determination of disability. They will review all the medical records and test results, and will frequently talk to the doctors directly, to make their own decision based on the evidence. Since the insurance company will look at the records themselves, they really don't care whether the doctor thinks you are disabled. Insurance companies look at letter created after the benefit denial with a jaundiced eye, seeing them as more likely the doctor's attempt to help out a patient rather than a fully accurate record.

This isn't true regarding the every-day medical records. They are created specifically to provide medical care, rather than to support a disability claim. They therefore have more credibility with the insurance companies than a letter explicitly supporting a disability claim. A scrawled note on a chart reporting that during a regular examination, the patient had slurred speech and difficulty getting on the examination table is more valuable than any letter the doctor and your lawyer create after the fact. This can go a long way to establishing that you are disabled, or that you are entitled to have coverage for a particular medical procedure.

How do you make sure your medical records are going to be able to help you in your claim? The first thing is to make sure you talk to your doctor. Particularly if you suffer from a condition that is not commonly diagnosed with objective tests, such as chronic fatigue syndrome, fibromyalgia, chronic Lyme disease, or significant back pain without substantial physical damage, you need to tell your doctor about the importance of the record to your claims.

The most important thing is to make sure your doctor notes any impairments he observes, such as slurred speech, memory issues, physical issues such as halting gait, guarded movements, pain observed on palpation, etc. It is hard for an insurer to claim that there is no objective medical evidence of a cognitive issue if the doctor has observed it in the course of a regular examination and has made a note of it.

The second thing is to tell your doctor about any episodes you had since the last exam that reflect your disability, and make sure she writes it in your record. An insurance company may claim that your claim that you can only ride in a car for 30 minutes was something that you just claimed recently in order to get disability benefits. If your doctor records this several times a year over a two year period, it is hard for the insurer to claim that you just came up with this limitation to get disability benefits. Also, if you do something that may be inconsistent with your limitations, make sure you tell your doctor any difficulty you had as a result. For instance, in one case, a claimant with a severe limitation on sitting decided he could not pass up the change to see a Game Seven of a Red Sox – Yankees American League Championship Series. The insurance company then said if you can go to a baseball game, you can go to work. The claimant was able to produce medical records, however, that showed he had to stay in bed for three days to recover. This went a long way towards establishing that while he may have been able to make an extraordinary effort occasionally, there was no way he could do so even two days in a row.

Make sure your medical records will support your disability claim. Talk to your doctor and make sure she writes down what you tell her, and what she sees. It is a good idea to get copies of your medical records periodically to see if your doctor is keeping notes that are going to help you. Then, when you do appeal the denial, or your lawyer is taking your case to court, you'll be in the best position possible to secure an award of benefits, whether it is long-term disability, short-term disability or coverage for a medical procedure.

If you have any questions about long-term disability benefit denial appeals, short-term disability benefit appeals, appeals of medical benefit denials or other ERISA benefit appeals, please feel free to call Brown Paindiris & Scott, LLP, whose is an experienced Connecticut long term disability lawyer and Connecticut ERISA attorney. The firm has offices in Glastonbury, Hartford, East Hampton and Bristol Connecticut, and he would be happy to discuss your benefit and ERISA appeals.