This is a good article written by Peter. R. Osagz.. The argument is well presented. What is not clear is who is going to make the workplace more accommodating for disabled workers. We have seen instances of disabled workers contacting their insurance companies for help in trying out some kind of gadgets that will enable them to work in some way. The companies responded by cutting off benefits claiming that the worker is fully able to return to work.
This is an issue which , if done right, can help increase profits for the insurance company and help the disabled worker contribute to the economy.
Wednesday, December 29, 2010
Adopting de novo standard of review of insurance denial still a far cry?
The standard of review adopted by a court in reviewing the decisions made by the insurance company or lower court is critical to the outcome of the case. Unfortunately, disability insurance companies frequently insert a clause in the policy document that allows the court to adopt a review that is most favorable to the insurance company. Potential customers should at least ensure that the policy document allows the courts to have, as far as possible, an unbiased standard of review.
For laypersons, more information about the standard of review here.
For laypersons, more information about the standard of review here.
Discovery: CIGNA forced to allow discovery after Glenn
Cigna attempts to block discovery but loses. It is interesting that some physicians seem to be repeatedly employed by multiple insurance companies. They always seem to concur that the claim is denied. Now why would that happen?
Full details here
Full details here
Senator Max Baucus takes cognizance of the inequity in ERISA disabiliy insurance
Full story here.
You can use websites like www.congress.org to send a mail to the lawmakers representing your area. As mentioned earlier in the blog, sweeping changes to legislation are a difficult task given the lobbying dollars and the reach of the insurance companies. Let us at least take baby steps by requesting the law makers to "require insurance companies to make full disclosure about the statistics of their approval / denial rates to their potential customers in the policy document"
Feedback from readers of this blog is welcome.
You can use websites like www.congress.org to send a mail to the lawmakers representing your area. As mentioned earlier in the blog, sweeping changes to legislation are a difficult task given the lobbying dollars and the reach of the insurance companies. Let us at least take baby steps by requesting the law makers to "require insurance companies to make full disclosure about the statistics of their approval / denial rates to their potential customers in the policy document"
Feedback from readers of this blog is welcome.
Tuesday, December 28, 2010
Can a Doctor Hired by a Disability Insurance Company Truly Be Independent?
When a policyholder files a disability insurance claim, the disability insurance company has the right to request that you undergo an independent medical exam or IME. In addition, the disability insurance company has the right to review your medical records, pay their own doctor to review your medical records, decide which medical tests to use in evaluating your claim, and hand pick which test results to take into consideration when evaluating your claim. Furthermore, the same insurance company serves as the "administrative board" in claims that are challenged or appealed by policyholders. This is especially true in ERISA type claims. Go here to learn more on ERISA claims.
Well, recently the United States Supreme Court handed down a decision that will begin shifting the balance a little more in the policyholder's direction regarding claims filed under ERISA. In the case, Met Life v. Glenn, the Supreme Court was faced with the following question(s): Can the same insurance company that pays a claim, also be the same entity that decides if payments be made or not? Can this structure or set-up provide a fair review of a claim?For the first time, the court decided that there is a conflict of interest that exists when reviewing the legitimacy of the claim determination.
This decision was followed by a federal court decision that stated that the independent medical exam or IME is not independent after all.
If a doctor is hired and paid by an insurance company to prepare an "impartial review" of the insured's medical records how can this be a true impartial analysis of the medical records when the doctor is literally on the insurance company's payroll.
Due to the U.S. Supreme Court's ruling, it will be interesting to see how other lower level courts decide on similar issues.
The Ninth Holds Hartford’s Claim Tactics Show its Conflict of Interest Improperly Motivated Long Term Disability Determination
From this article:
The Ninth Circuit reversed a long-term disability denial by Hartford Life Insurance Company based on its “over-reliance” on surveillance in which it “strung together a laundry list of discrete activities over the course of four days” thereby suggesting that the Plaintiff would be capable of performing such activities throughout the day. The Court noted that the ability to perform sedentary work “in bursts” did not amount to the ability to sustain a full time occupation. The Court also criticized Hartford for glossing over the difficulties that were observed in the surveillance, such as stiffness and slow movement, instead making the conclusion that the claimant had no limitations or physical distress. The Court opined that such overstatements about the observed activity then improperly influenced the claimant’s physician when he was asked to respond to such surveillance. Also at issue with the Court was Hartford’s “paper” review versus an in-person” exam, not because such exam was required by the Plan, but because the paper review, along with the over reliance on the surveillance, reflected signs of bias. The Court also disagreed with Hartford’s rationale for denial concerning the Plaintiff’s lack of further degeneration of his degenerative back condition, and noted that after paying the claimant for 2 years, one would expect benefits to be terminated if his condition improved, and not due to the lack of progression. The Court also believed that Hartford wrongfully disregarded the finding of disability by the Social Security Administration without comparing and contrasting it, after reaping the benefit of the dollar-for-dollar offset. Montour v. Hartford
The Ninth Circuit reversed a long-term disability denial by Hartford Life Insurance Company based on its “over-reliance” on surveillance in which it “strung together a laundry list of discrete activities over the course of four days” thereby suggesting that the Plaintiff would be capable of performing such activities throughout the day. The Court noted that the ability to perform sedentary work “in bursts” did not amount to the ability to sustain a full time occupation. The Court also criticized Hartford for glossing over the difficulties that were observed in the surveillance, such as stiffness and slow movement, instead making the conclusion that the claimant had no limitations or physical distress. The Court opined that such overstatements about the observed activity then improperly influenced the claimant’s physician when he was asked to respond to such surveillance. Also at issue with the Court was Hartford’s “paper” review versus an in-person” exam, not because such exam was required by the Plan, but because the paper review, along with the over reliance on the surveillance, reflected signs of bias. The Court also disagreed with Hartford’s rationale for denial concerning the Plaintiff’s lack of further degeneration of his degenerative back condition, and noted that after paying the claimant for 2 years, one would expect benefits to be terminated if his condition improved, and not due to the lack of progression. The Court also believed that Hartford wrongfully disregarded the finding of disability by the Social Security Administration without comparing and contrasting it, after reaping the benefit of the dollar-for-dollar offset. Montour v. Hartford
Struggle with social security
We recognize that many of the readers of this blog also consider applying to social security. This is a good informative blog for those applying for social security.
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