Things you should know when advocating for insurance benefits for RA
Written by Kantor and Kantor insurance Matters on January 14, 2013
Invisible diseases are often complex, mysterious, and complicated. Because of the uncertain nature of these conditions, the search for a diagnosis (or multiple diagnoses) can be a very demanding and prolonged process. Patients are faced with two challenges: (1) the internal suffering and symptoms they experience may not be acutely apparent to others, and (2) the cause, treatment, or test for these illnesses may not be exact. As a result, the patient may be faced with a number of differing opinions.
Unfortunately, the ambiguity in diagnosis and treatment presents the perfect opportunity for insurance companies to deny claims for treatment. For the last 20 years, Kantor & Kantor has, and continues to represent individuals whose disability claims have been wrongfully denied by their insurance company. Three themes are seen over and over again in insurance company denials of disability benefits.
1)Lack of Objective Evidence
Insurance companies will deny a claim based on lack of objective evidence. Objective evidence does not exist for invisible diseases, and so we cannot objectively prove the illness in a traditional way. This presents another challenge for those already struggling with pain and discomfort! Be aware that the treatment notes from your physician are considered clinical documentation that should satisfy any need for objective verification. Thus, it is critical that your treatment providers accurately record your symptom severity against a clear baseline. For example, if you are feeling “better,” your treatment provider needs to clarify the level you were at before – and preferably quantify what feeling better means for your functional ability. Medications and therapies should also be fully discussed.
2)Symptoms are Excessive
To those who are not knowledgeable about Rheumatoid Arthritis, symptoms of the disease might sound excessive. Much of the suffering is self-reported and cannot be measured with tests or machines. It is important to be consistent with doctor visits and the application of recommended medications and therapies. This will lend credibility to the severity and reality of the symptoms. Your doctor’s notes and diagnosis then become consistent with your reported symptoms.
3)Claims that Activity Level is Inconsistent with Claimed Level of Impairment
Insurance companies will try to take advantage of gaps of information. It is very important that you be as thorough as possible. For example, say you check a box on a form saying you are able to drive. This does not tell the insurance company that you only drive a mile down the road once a week and before taking your medications to do your banking. On its face, without this information, an insurance company may doubt your level of impairment. Thus, make the effort to explain the modifications in your ability to drive. It is important that you transmit the full picture to the insurance company, and to do so in writing. Do not be afraid to document everything in writing or to keep an activity journal. Explain in detail how long it took you to complete a task, how difficult it was for you, the assistance you needed to accomplish a task, or any other modification from how you used to perform the task. When completing forms provided to you, do not feel constrained by them. Feel free to amend them for clarity or write more than the space on a form allows. Record all the difficulties you are having, but do not exaggerate. Insurance companies are allowed to and do conduct surveillance. Inconsistencies between your claimed level of activity and your observed level of activity does not help get your claim paid. Even if the observed level of activity is minimal, if you did not report this, it will be held against you by the insurance company.
Every day, Kantor & Kantor gets a glimpse of the struggles and hardships our clients face when living with disabling conditions. Life is difficult for our clients. We understand that being denied disability coverage only exacerbates the situation. We fight for our clients to get their insurance claims paid – all the way to Court. If you or someone you know has been denied disability or other health related benefits, call (800) 446-7529. We can help.