Most dentists know that if they file a disability claim, there’s going to be an investigation. Many dentists have heard stories about surveillance, or biased medical examiners, but tell themselves, “that won’t happen to me, because I’m filing a legitimate claim.” They think that all they’ll have to do is submit a note from their doctor (who is supportive) listing their limitations, and they’ll be able to collect their benefits right away. They don’t realize that, in addition to the claims analyst that they’re interacting with, the insurance company has a team of in-house doctors, attorneys, vocational experts, etc. working collectively behind the scenes, exploring any weakness that can be used to justify denial of the claim. Then, when the insurance company conducts an on-going, full-scale investigation, it catches them off-guard and unprepared.
So what do you need to be prepared for, if you’re thinking of filing a disability claim? Below is a list of just a few of the primary tools insurance companies use to investigate (and deny) claims. (The list below is not exhaustive, and is merely intended to provide a broad overview of what the disability claims process entails.)
Interviews
• Phone interview. As we explained in our last post, your insurer may require that you submit to an interview regarding your disability, health and work history, and activities in the very first call, before you even have a chance to talk to an attorney, or review the questions on the initial claim forms.
• Field interview. In most instances, insurers will send an agent to interview claimants, typically in their homes, and will record the conversation. Most policies also contain a provision that states a claimant won’t receive benefits if they don’t consent to this interview. The interviewer will ask a wide range of questions about the claimant’s employment, disability, claim, return to work efforts, etc. While the interviewer may seem friendly and casual, the questions can become intense or invasive, and these field interviews can last anywhere from 45 minutes to, in some cases, four hours or more.
• Friends and family. An interviewer (or private investigator) may show up when he or she knows a claimant won’t be home, in an attempt to speak with friends or family members that are present about the claim.
Surveillance
• Private Investigator. Using information from the interviews and claim forms, your insurer may employ a private investigator to record you as you go about your daily activities. This may include watching you from outside your house, following you while driving, taking videos or photos of your activities, and even interviewing your neighbors. We’ve also been involved in multiple matters where overzealous investigators have trespassed on private property, and another matter where the investigator went so far as to place a tracking device on the claimant’s vehicle.
• Online surveillance. This can include following you (or your family/friends) on social media, checking public records, searching online court databases, pulling credit reports, and reviewing Board complaints or other documents related to your license. Even if you’ve implemented privacy settings on your social media, some investigators may use fake accounts and try to “friend” or follow you (or your family members), to gain access to your social media posts, photo albums, etc., so it’s important that you only accept “friend” requests from people that you know personally.
Exams
Many policies contain provisions that allow the insurer to require a claimant to submit to exams in order to receive or continue to receive benefits. Some common examples are:
• Independent Medical Examination (IME). Notwithstanding its name, this is a medical examination performed by a doctor of the insurance company’s choosing and at their expense. This doctor will be given access to all your medical records, and any surveillance footage the private investigators were able to collect.
• Functional Capacity Examination (FCE). A series of tests designed to evaluate an individual’s capacity to perform work activities related to his/her employment.
• Neuropsychological Evaluation. A testing method designed to obtain data regarding an individual’s cognitive, motor, linguistic, behavioral, and executive functioning, which will explore potential secondary motives for filing the claim, and the prospect of malingering.
• Vocational Evaluation. A vocational expert will evaluate a claimant’s job duties pre-disability, and then express his/her opinion on whether a claimant can return to work (on either a full-time or part-time basis), and whether there are any workplace modifications or accommodations that would allow the claimant to return to work.
Records
At the outset of your claim, you will be asked to sign an authorization that allows the insurance company to access a vast amount of data, which typically includes the following:
• Medical and pharmacy records. (This means not only records related to your disability, but those from your entire health history.)
• Financial documents. (This can include tax returns for you, your business(es), and/or your trust(s); other income information; and information regarding investments.)
• Production codes.
• Profit and Loss statements.
• Employment agreements.
• Practice purchase or sale documents.
In addition to allowing insurers to access a wide array of records, the authorization also allows the insurer to speak with individuals who may have information about the records specifically, and you in general, including:
• Your doctors.
• Pharmacists.
• Benefit plan administrators or an HR department.
• Social Security Administration.
• Financial institutions, consumer reporting agencies, and brokers or agents.
• Employers, co-workers, and employees.
Most of the time, the insurer will not give you any advanced warning, or even tell you that they have contacted these people until you receive the denial letter. And newer disability policies are now including a provision stating that these authorizations cannot be modified (which essentially grants the insurer the ability to seek out any information they want, whenever they want it).
As you can see, submitting your claim forms and initial proof of your disability is only the beginning. In future claim tips, we’ll be looking at many of these investigation tactics in more detail.
Information offered purely for general informational purposes and not intended to create an attorney-client relationship. Anyone reading this post should not act on any information contained herein without seeking professional counsel from an attorney.