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Healthcare providers Roles of professionals Completing private insurance forms

Completing private insurance forms

Faith Hayman, Trial and Appellate Lawyer

Ms. Faith Hayman graduated from Osgoode Hall Law School, Toronto, in 1983. She represents clients pursuing primarily personal-injury actions and disability-insurance claims. Ms. Hayman was on the executive of the BC Trial Lawyers’ Association for 10 years and, for the last several years, has chaired the Rules Committee. She serves on the Board of Governors of the Trial Lawyers Association of British Columbia and is also a member of the Ethics Committee of the Sunny Hill Health Centre for Children. Ms. Hayman has argued court cases at all levels, including the Fidler v. Sun Life decision in the BC Court of Appeal and the Supreme Court of Canada.

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It can be hard to know what to say on an insurance form that will persuade insurance companies to accept or maintain a disability claim. Here are some suggestions:

1. Match job requirements with functional impairments

When completing a claim for disability benefits and progress notes, it is important to have a basic understanding of the patient’s job requirements. The essence of all job requirements is that an employee will perform:

  • a number of tasks
  • accurately and effectively
  • within a set period of time
  • on a long-term basis (i.e. not just over two days)

As a general rule, a person must be able to do all of the above in order to stay gainfully employed.

Once you understand your patient’s job requirements, set out the person’s limitations in relation to those requirements. For example, do they have:

  • mental or physical fatigue?
  • pain?
  • cognitive problems?

Are these symptoms known features of cancer or side effects of treatment? If so, be sure to mention this and explain how these impairments will impact the patient’s ability to work. The more effectively the limitations are linked to the job demands, the more relevant the medical opinion is to the disability claim.

2. Address fluctuations, improvement and long recovery time

Some cancers or treatments may have symptoms that wax and wane. It is not uncommon for insurers to terminate benefits when symptoms diminish, although the illness itself continues and symptoms will likely return. In these cases, it helps if you clarify in your opinion that the patient remains disabled despite temporary periods of improvement.

In other cases, a patient may be improving and their benefits are terminated on the basis of that improvement. If the patient still has a long recovery ahead before they are ready to return to work, it is important to contextualize the improvement in your opinion. For example, you could say,

The patient has improved from 2 to 3 out of 10, but she will need to be at 8 out of 10 in order to start a graduated return to work.

3. Highlight efforts to recover and motivation to return to work

Insurers are more inclined to pay benefits if they know that a patient is dedicated to their recovery and highly motivated to return to work. This includes attending rehabilitation programs, reaching out for counselling support and joining cancer-related rehabilitation or support group programs. It helps to describe the patient’s efforts at rehabilitation with a view to recovering and returning to work.

4. How to handle disputes and appeals

When disability benefits are wrongly denied, especially after extensive medical documentation has been provided, it may help your patient if you offer to speak with the insurer’s medical advisor. You might also suggest that the insurer arrange for an independent medical examination by a specialist such as a:

All insurers retain medical advisors and all policies give insurers the right to require an insured person to undergo a medical examination, so speaking to the medical advisor and suggesting an independent medical examination are appropriate ways to handle disputes and appeals.

5. How to address an insurer’s demand for objective evidence

Sometimes insurers wrongly deny benefits citing a lack of objective evidence. Disability insurance policies generally do not require that the insured person provide medical evidence of disability because such a requirement is unreasonable if no such evidence exists. If there are no objective tests for your patient’s symptoms (for example, chronic pain), it is important to:

  • State that no objective tests for your patient’s disability exist.
  • Identify in some detail the symptoms reported by the patient.
  • Give the relevant factors that support your opinion.
  • State that these should also be sufficient to support the disability claim.

6. Avoid giving a prognosis

Sometimes insurers want doctors to give a prognosis. It is important to distinguish between a medical prognosis and an insurance or return to work prognosis, which insurers rely on to decide whether and for how long disability benefits should continue to be paid.

Providing a prognosis is also challenging because it requires you to predict what will happen in the future. There is often a range of outcomes based on a number of different variables. Even where the patient has largely recovered, they may continue to experience disabling symptoms, either from cancer or its treatment.

Given these uncertainties and the consequences that attend an insurance prognosis, it is best to exercise caution. If it is premature to provide a prognosis, it would be best to say so and suggest that the patient be reviewed again in the future. If a prognosis can reasonably be given, it is best to provide a likely range of recovery periods and include caveats (i.e. if the patient continues to improve, then…) and outline what symptoms the patient may continue to struggle with even after they are largely recovered, particularly if those symptoms have the potential to interfere with the patient’s ability to work.

7. Address risk of deterioration

Disability insurance is sold to cover a person’s basic financial needs when they are too disabled to work. When wrongful denial or termination of benefits will likely increase your patient’s stress and thereby contribute to deterioration in their condition, it is important to tell insurers. Make clear that the patient is at risk of deterioration if benefits are denied or terminated.