You submitted a claim for benefits, or have been receiving disability benefits for a couple of years, and then the insurance company or the plan writes you and tells you, in effect, “our doctors say you are no longer disabled.” Sometimes it is relying upon a doctor who actually examined you in what they call “an independent medical examination.” But usually they only have a report from a nurse or doctor who merely read your records. Who are these doctors who don’t know you and how do you fight back against their unfair reports?
First, even though the insurance companies and plans always characterize these doctors as “independent” they really aren’t. Some work directly for the insurance company; most work for third party services which, in turn, are contracted with the insurance companies or plans. Many of these doctors make a lot of money writing reports for insurance companies and have an obvious economic incentive to provide opinions favoring the insurance company’s or plan’s economic interests in order to continue to get regular work.
Some of these doctors lie or have lied about their credentials or qualifications. Some of these doctors have lied to state licensing boards about criminal problems in their past. Some of these doctors have been disciplined by state medical boards. Many of these doctors have no patients and no hospital privileges, but only write reports for insurance companies. That is, a lot of these doctors are not credible or believable. But unless you expose them for what they are how is a judge to know that when you are forced to file suit to get your benefits?
Of course, a lot of these doctors are real doctors with active practices who write medical reports on the side. But even those doctors are not necessarily credible or reliable. First, often they do not write the reports. Instead, the service which hires them or the insurance company which contracts with them writes much of their reports. Second, they are often given a limited amount of time in which to review records and write reports. Third, they are often instructed to disregard certain types of evidence so that their reports do not actually reflect medical reality but only appear to do so.
Hundreds and thousands of ERISA cases are decided by courts each and every year in favor of insurance companies or plans based on reports attributed to such doctors who never examined or treated the claimant, spent a minimal amount of time reading the claimant’s records, often don’t practice medicine anymore or have serious credibility problems based on prior discipline or misrepresenting their credentials, didn’t write most or all of the report but let some clerk at the insurance company or the service do so, and who make a great deal of money writing such reports – – but judges rely upon these doctors’ reports because they didn’t know any of these facts and, on the face of the report, the doctor is independent, qualified, and has addressed the issues relevant to the case. All benefit cases do not go to court. But if your case does go to court, and it involves a medical issue, you need to demonstrate that the insurance company’s or plan’s doctors’ opinions are not credible or reliable or you are likely to lose.