We often see claims denied or terminated based upon the report of a reviewing physician’s alleged conversation with a client’s treating physician. Problems frequently arise when a physician retained by the insurance company attempts to contact an insured’s attending physician to discuss an insured’s claim. Unfortunately, the insurer’s physicians do not make an appointment to speak to the insured’s physician and prefer to “cold call” the attending physician in the midst of a busy practice schedule. This creates several problems. First, the attending physician may not be able to take the call because he or she is treating patients. As a result, the insurer’s physician notes that the attending physician did not take his call and an implication is raised that the insured’s physician does not support the claim.
Second, even if your physician is able to take the call, he or she may not be prepared to thoroughly discuss the claim or the restrictions and limitations without a review of his or her records. If pressed for answers regarding the date of last examination or clinical findings, the attending physician may not be able to give complete or accurate answers.
Finally, we often find that the questions posed to the treating physician are misleading or incomplete. For example, the reviewing physician may ask the treating doctor if the insured is able to work or “do something.” This may not be the accurate criteria for disability under your policy. The ability to work part time or perform another occupation may not be the correct definition of disability under the Policy. The reviewing physician may then write a misleading report, indicating that the treating physician was “in agreement” that the insured could “return to work.”
For these reasons, we insist that any communications between an insurer’s reviewing physician and the insured’s doctor be in writing. The reviewing doctor can write the treating physician a letter, asking the questions that are pertinent to the claim. The treating physician can respond to the letter in writing, with the benefit of reviewing the most recent medical records.
If your physician has already had a conversation with the insurer’s doctors, it is best to ask your physician what was said during the conversation. You should put this in writing and send a copy to the insurance company. The claim file should have an accurate description of what was actually asked and answered as opposed to the reviewing physician’s re-characterization of the conversation.