This is what a disability claim frequently comes down to. But as an insurance adjuster, you’re the one sifting through all the complications that get in the way of the question.
Let’s talk about some of those things. Understanding what the problems are is the first step to solving them, after all. When they’re all laid out, it’ll be clear how the solution we’ve got can deliver clarity on everything.
- Is the disability physical or mental?
- Are they completely unable to do their existing job?
- Are they able to do parts of it with employer accommodation?
- How does the case intersect with potential WCB payments?
- Does the medical documentation seem incomplete?
- Does the policy bar them from doing any work they’re capable of, or just their current job?
- Do you have reason to believe they’re still working?
- Is it likely that the claimant is able to return to work within a few weeks, months, years?
Or will they never return at all?
Spotting the Gaps in Disability Claims
There’s what the claimant’s telling you, and there’s what’s really going on. Certainly there are many cases where these are in sync: the person is suffering what they’re claiming to suffer from, they meet all the requirements, they need the payments, and it’s an easy approval.
But there are the cases with gaps. Perhaps they’re suffering something, but not quite to the extent they claim. They’re capable of doing work, but they’re claiming it’s just not possible. Or the issue is accurately presented, but doesn’t actually meet the policy’s requirements.
A few important suspicious red flags to watch out for are long term disabilities lasting longer than expected, chronic pain that isn’t objectively verifiable and relies on the patient themself to report, and a history of prior injuries and claims.
What Can Disability Insurers Do to Address Uncertainty?
There are many methods insurers use to confirm the existence, extent, and longevity of a disability.
- Request more information from the claimant’s doctor
- Statistical predictions that guide expectations
- Surveillance techniques to directly observe and confirm the claimed disability
- Independent Medical Advice
That last one is a powerful tool when you’ve spotted a few red flags and are faced with uncertainty — and the prospect of a lengthy appeals process if you deny benefits.
Independent Medical Advice: The Best Strategy to Clarify a Disability Claim
Disability insurers can quickly access an Independent Medical Examination (IME). This involves retaining an independent medical expert to assess the issues, and provide the clarity you need for decisions on the file. It also helps you navigate the difficult world of medicalization: when a non-medical issue gets unnecessarily promoted to the status of medical problem.
Want to know a little more about Independent Medical Examinations for disability insurers? We’ve got a great starting point right here. Find out what we do, how we can guide you through complicated medical opinions, and get access to a shareable eBook starter pack. It’s all available right here.