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Avoiding Claim Denials

Build a Strong Claim Right from the Start

In the matter of insurance claims (and disability claims in particular), it is generally true that “the best defense is a good offense.”  It will be easier to gain approval of a disability claim — whether in the first instance or after a denial — if you have laid a foundation well in advance of ever filing the claim.

  • Don’t be stoic.  Although it is important to keep an optimistic disposition in the face of chronic illness, bear in mind that disability claim examiners latch onto patient comments such as “feeling good today” — frequently recorded by physicians in their medical charts — as a basis for concluding that a claimant is not disabled. Do keep a positive outlook, but also make sure you affirmatively report and carefully describe your symptoms. Be specific, concrete, and document any limitation on your ability to work or your activities of daily living (or “ADL’s”), such as cleaning, cooking, self-care, grocery shop­ping, socializing, etc. Instead of saying only that you are “very tired,” report that you must take 1-hour naps (at the office), are sleeping 10 instead of your normal 7-8 hours at night, are arriving late to (or leaving early from) work due to exhaustion, have stopped cooking your own meals in favor of “ordering in,” et­c. Such specifics will not only help document an insurance claim, but will do a bett­er job of communicating to your doctor the nature and severity of your disabling symp­toms.
  • Make sure your doctor takes notes.  Many physicians fail to document patient symptoms — because the symptoms have not worsened or improved, or because the symp­toms are unnecessary for diagnostic purposes. Disability claim examiners, nonetheless, will insist that if a symptom does not appear in a doctor’s medical chart, it either did not exist or wasn’t severe enough to be disabling. Impress upon your doctor the importance of charting symptoms (with specificity), and that a little investment of time during each office visit may avoid substantial expenditures of time later preparing narrative letters in support of a denied disability claim. Similar advice is applicable to long term care claims. It is imperative for a home health aide or nurse to specifically document all assistance or care provided. Failure to note assistance with the required number of “ADLs” (activities of daily living, such as bathing, feeding, toileting, transferring, dressing, etc.) may disqualify a claim. While most home healthcare agencies require homecare providers to complete daily care logs to document such activities, privately hired aides and nurses may need to be instructed to maintain such daily logs.
  • Keep copies of all medical records as you go along.  Nothing is worse than trying to collect extensive medical records from multiple health care providers in order to meet a tight deadline for a supplemental “update” request or the appeal of a denied long term care or disability claim. In the case of a supplemental long term care and disability claim update requests, the failure to provide a timely response may result in the suspension or termination of benefits. Getting your records can be even more harrowing when a doctor has, in the meantime, died, moved, or otherwise sold his or her practice. Hospital record departments are notoriously slow in responding to requests. You are entitled to your medical records, upon submitting a signed authorization. Be sure to do so (or to create a medical records portal for direct access), and to follow up and get those records. It will save you headaches and delays later, and also gives you a means to verify that treating physicians are fully and accurately recording your disabling symptoms and complaints.
  • Provide as much detail and documentation as possible when submitting your claim. Don’t confine yourself to the little boxes on a claim form. Attach extra shee­ts to identify all your doctors or to desc­ribe your disabling symptoms (and their ­ef­fect on your functioning) in detail.  Get your physi­cian(s) to submit a letter (or letters) in support of your claim. To be effective, such letters should not simply state a medical conclusion, but should instead summar­ize your diagnoses, medical history (­symptoms reported, physical examina­tion find­ings, laboratory and test results, treatment history, current medications and side effects, com­plications, referrals to other doctors, etc.­), and then the conclusion (for example, that you are “dis­abled,” that you require assistance or supervision with regard to certain ADLs, or that a proposed treatment is “med­ically necessary”). If making a disability claim, you should be sure your doctor knows your occupation, your important job duties, and how your illness or symptoms disable or prevent you from performing those duties.
  • Consider an Attorney Consultation:  Perhaps the most cost-effective time to consult a lawyer is before you file your disability claim, or, in the case of expensive surgical procedures or drug regimens, before you initiate the treatment. Our attorneys can review your insurance policy or plan documents and, in light of their experience dealing with insurance companies, can advise you about particular items of medical proof, contractual arguments, or other support which might facilitate the approval of your life, health or disability benefits.

TELEPHONE:  212-406-9606

Mark Scherzer Law :: New York Long Term Care and Disability Claim Lawyers :: ERISA and Insurance Lawyers :: Health Insurance Claim Denials
New York Attorneys (including New York County, Bronx County, Richmond County, Queens County, Kings County, Nassau County, Suffolk County, Westchester County, Rockland County, Orange County, Putnam County, Sullivan County, Ulster County, and Dutchess County)

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  • New York Office
    110 Lasher Avenue
    Germantown, New York 12526
    Phone: 212-406-9606
    Fax: 212-964-6903
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