Which doctor can certify your long term disability?

Recently we won an insurance appeal for a client whose disability insurance company had denied a portion of his long term disability claim because the physician who filled out the attending physician statement was not the doctor who had treated him from the onset of his disease process. The insurance company said “because your doctor was not treating you during the onset of your claimed disability he is not qualified to certify your disability.”

As part of our claim review process we reviewed the insurance policy and updated our legal research. We noted that the insurance policy did not require certification from a physician who “was treating you during the onset of the claimed disability.” We pointed out that physicians routinely rely on past medical history for diagnosis and treatment, so the insurance company had no logical reason to disqualify a physician from giving an opinion regarding an earlier disability date solely because they were not treating them on that earlier date. The insurance company agreed and sent our client a check for $110,000 in back benefits.

It is important to note that the client had been attempting to address this issue with the insurance company for at least a year. The insurance company kept saying “no”. Our extensive appeal, which included legal research and a threat that we were going to file suit here in Virginia caused the insurance company to take an in-depth look at their denial and to reverse its prior long term disability claim decision.