Invisible Diseases and Insurance Companies: Challenging and Preventing Insurance Denials

By Kantor & Kantor, LLP

Invisible diseases are often complex, mysterious, and complicated. Because of the ambiguous nature of these conditions, finding a diagnosis (or more than one diagnosis) can prove to be a difficult and prolonged process. Patients are faced with two challenges: (1) the internal suffering and symptoms they experience may not be acutely apparent to others, and (2) a precise cause, treatment, or test for these illnesses may not be exact. As a result, a patient may be faced with a number of differing opinions.

 

Unfortunately, many insurance companies use this uncertainty in diagnosis and treatment as an opportunity to deny claims for treatment. At Kantor & Kantor, we have represented scores of clients with invisible diseases such as Lupus, Arthritis, Fibromyalgia, and Chronic Fatigue Syndrome. These clients sought our assistance when their disability claims were wrongly denied by their insurance companies.

 

Over the years, we have seen three main themes emerge from insurance companies concerning disability benefits.

  1. Lack of Objective Evidence
    Insurance companies will deny a claim based on lack of objective evidence. The problem with this reasoning is that objective evidence does not exist for invisible diseases. We cannot objectively prove the illness in a traditional way. Rather, we provide verification of symptoms or testing of functionality. Be aware that the treatment notes from your physician are considered clinical documentation that should satisfy any need for objective verification. Thus, it is critical that your treatment providers accurately record your symptom severity against a clear baseline. For example, if you are feeling “better,” your treatment provider needs to clarify the level you were at before – and preferably quantify what feeling better means for your functional ability.
  2. Symptoms are Excessive
    Symptoms of these diseases may sound excessive to those who are not knowledgeable about them. Much of the suffering is self-reported and cannot be measured with tests or machines.  It is important to be consistent with doctor visits and the application of recommended medications and therapies. This will lend credibility to the severity and reality of the symptoms. Your doctor’s notes and diagnosis then become consistent with your reported symptoms.
  3. Claims that Activity Level is Inconsistent with Claimed Level of Impairment
    Understand that insurance companies will try to take advantage of gaps of information. For example, say you check a box on a form saying you are able to drive. This does not tell the insurance company that you only drive a mile down the road once a week and before taking your medications to do your banking. On its face, without this this information, an insurance company may doubt your level of impairment. Thus, make the effort to explain the modifications in your ability to drive. It is important that you transmit the full picture to the insurance company, and to do so in writing. Do not be afraid to document everything in writing or to keep an activity journal. Explain in detail how long it took you to complete a task, how difficult it was for you, the assistance you needed to accomplish a task, or any other modification from how you used to perform the task. When completing forms provided to you, do not feel constrained by them. Feel free to amend them for clarity or write more than the space on a form allows. Record all the difficulties you are having, but do not exaggerate. Insurance companies are allowed to and do conduct surveillance. Inconsistencies between your claimed level of activity and your observed level of activity does not help get your claim paid. Even if the observed level of activity is minimal, if you did not report this, it will be held against you by the insurance company.

 

What Can You Do to Prevent a Denial?
Be your own best advocate!

Your general focus should be explaining the full picture of your illness and life, as that may not always make it into your treatment notes. This gap in documentation and quantification is something the insurance company may seize upon to find that you have not supported your claim. Remember, it is your burden under the policy to prove your claim. Because these illnesses can lack distinct diagnoses and objective evidence, it is imperative you focus on the symptoms of your illness and how those symptoms affect your life. Do your best to quantify your impairment. Even without a firm diagnosis, your physician can verify your symptoms in clinical notes and quantify the extent to which they interfere with your daily living.

Be sure to communicate with your physician and explain the steps you need to take when completing a task. Put this in context. Recognize that comments such as “okay” or “stable,” used on forms or during exams with your physician, may be misconstrued by your insurance company to support an argument that you are not disabled. Do not be afraid to speak with your doctor openly and ask him or her to record this complete picture in your treatment notes. Your records may one day end up in the hands of the insurance company. If you and your doctors accurately articulate how you are feeling and the effects the illness has on your life, and the manner in which these things impair your capacity to work, it will be much more difficult for the insurance company to deny your claim.

Every day, Kantor & Kantor gets a glimpse of the struggles and hardships our clients face when living with disabling conditions. Life is difficult enough for our clients. We understand that being denied disability coverage only exacerbates the situation. To stop this from happening, we fight for our clients to get their insurance claims paid – all the way to Court.

Kantor & Kantor is one of the most experienced and highly respected law firms dealing with the prosecution of claims against insurance companies. We represent clients whose insurance companies have failed or refused to pay claims arising out of Disability, Health, Life, Long Term Care and other liability insurance claims.  If you or someone you know has been denied disability or other health related benefits, call (800) 446-7529. We can help.

Kantor & Kantor, LLP
19839 Nordhoff Street
Northridge, CA 91324
(818) 886-2525 ext. 5000
www.kantorlaw.net

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