The answer to this question may seem obvious. Of course, long-term disability (LTD) insurers need medical records to determine whether you’ve suffered from a qualifying condition. However, does your claim’s adjuster really need your pregnancy records from 20 years ago? Because don’t be surprised when they request them there’s a nefarious reason behind it.
Nearly all private LTD insurers are actually looking for evidence of pre-existing conditions sufficient to justify denying you benefits. If you complained of back pain during your pregnancy, don’t be surprised if adjusters deny your spinal injury claims based on reported pain from 20 years ago. This seems like an extreme example, but it’s common industry practice.
Adjusters count on disabled claimants granting them access to unlimited medical records before claimants discuss their rights with experienced long-term disability attorneys. The right disability lawyer will know the permissible scope of medical records requests and will challenge pretextual LTD denials. Reach out to a trusted law firm to schedule your free and confidential long-term disability benefits consultation.
Understanding Permissible Long-Term Disability Insurance Requests
To prevent fraud and ensure legal compliance, your long-term disability provider may request reliable evidence of a qualifying disability according to your policy terms.
This most often includes requiring claimants to provide:
- A complete claims form.
- HIPAA authorizations to obtain medical records directly relating to the claimed condition
- HIPAA authorizations for general medical records, such as those from primary care physicians, or records referenced by primary medical documentation
- Accident reports and witness statements
- Disability certifications from doctors, including periodic re-certifications
Further, providers may require claimants to attend independent medical examinations (IME) with allegedly neutral doctors and specialists. You must meaningfully participate in these appointments, but experienced attorneys can challenge the ultimate IME report with conflicting medical records from personal doctors
Unfortunately, most insurers do not stop after receiving primary medical evidence certifying your disability. They often request excessive, old, and irrelevant medical records when they cannot find a clear reason to deny your claim. Don’t be surprised if these requests include demands for authorizations related to OBGYN records, mental health counseling, substance abuse treatment, and other deeply private matters unrelated to the disabling condition. In many cases, you do not legally have to provide these authorizations.
Identifying and Defeating Common LTD Insurance Tactics
During litigation, the law (FRCP 26) prohibits parties from requesting evidence that’s irrelevant to the claims, disproportionate to the needs of the case, unreasonably cumulative, and overly burdensome.
These protections allow attorneys litigating ERISA claims to directly challenge irrelevant, private, and overly burdensome medical records requests. Long-term disability insurers seldom abide by these rules during the initial claims process. Instead, adjusters take advantage of unrepresented claimants by using the following tactics to obtain irrelevant medical documentation.
#1. Citing Contractual Obligations
Private long-term disability coverage stems from a policy, which is a contract between the provider and beneficiary. This includes intended third-party beneficiaries employees under employer-sponsored insurance plans. These extensive contracts generally include terms requiring claimants to provide medical releases for all medical records deemed relevant to the claims.
Refusing to prepare and provide these extensive authorizations may result in accusations that you’ve violated the contract’s terms and cannot obtain benefits. Claimants often mistakenly believe that adjusters who are not qualified ERISA attorneys have the final say in such matters. They do not.
Courts have continuously limited insurance companies’ rights to violate your privacy by requesting medical releases for records not reasonably related to your condition. If your adjuster claims your policy requires certain medical documents, bring your concerns to a dedicated disability lawyer. We answer any question you have free of charge during your initial disability case consultation.
#2. Threatening to Delay Claims Review
Claimants frequently receive letters informing them that failing to provide the requested authorizations beyond those directly related to the injury/illness will potentially delay their claims review and benefits release. Because long-term disability insurance compensates eligible beneficiaries for essential lost income, most claimants cannot afford claims delays.
They may simply provide the requested authorizations to prevent another month of financial strain without considering the real reason adjusters want the documentation, i.e., they’re looking for pre-existing conditions. A simple letter from an attorney may remind adjusters of their legal obligations and force a timely claims review.
#3. Claiming Insufficient Records
Even when adjusters receive the initial proof of loss, i.e., hospital records, accident reports, and physician letters, they may send letters claiming they need additional medical records to review the claim. Again, they’re often looking for reasons to disprove your claims, not support their legitimacy.
Experienced ERISA attorneys know what evidence is considered sufficient to trigger LTD benefits under traditional policies and may object to demands for unrelated or overburdensome medical authorization requests.
#4. Warning of Potential Denials
In some cases, adjusters will warn claimants that they discovered a potential reason for denial and need additional evidence to help prove your claim. Some adjusters legitimately care about your eligibility, but most don’t. Their objective is to help their employer’s bottom line by minimizing policy payouts. Private insurance is a for-profit business that operates by the numbers. It’s almost a guarantee that, no matter how many additional authorizations you provide, adjusters will only find additional reasons to support a denial.
Do not let adjusters bully you into releasing irrelevant and private medical records. Private disability insurers have teams of reviewers trained to identify and link pre-existing conditions to your current claims. They’re not looking for supporting evidence; they’re looking for the opposite. If you receive a seemingly irrelevant request for medical authorizations during the LTD claims process, discuss your rights and obligations with an experienced disability lawyer.
Options for Limiting Medical Records Requests in Long-Term Disability Claims
In many cases, LTD adjusters continuously request medical authorizations until the claimant pushes back. They take everything you’ll give them and use it against you. They do not request old and irrelevant medical releases unless they are looking for disqualifying evidence. Here are some ways to refuse excessive medical records requests from long-term disability insurers and preserve your claims.
Respond to Requests without Providing Medical Authorizations
Always respond to insurance requests, as adjusters may use communication and cooperation failures to deny your claims. However, this does not mean you’re obliged to provide the requested information. Respectfully address each request by stating that you will not provide certain authorizations and explaining why the demand is irrelevant, overly burdensome, cumulative, or unavailable. An attorney should generally prepare and send these communications on your behalf, however, certain adjusters may cease demanding additional information if you assert yourself.
Consider these examples:
- “I’ve received your request for authorizations and medical information dated April 13, 2020. I intend to seek legal advice about the legality of the requested documentation under relevant ERISA and healthcare privacy laws.”
- “All authorizations for records relevant to the present claims were duly provided on or about April 10, 2020. As such, I will not be providing authorizations for additional and irrelevant medical records and will hire a lawyer.”
- “The present claim arose from a car accident on May 2, 2020, resulting in neck pain. As such, my podiatry and obstetrics records are irrelevant to the present claim and unduly infringe on my privacy.”
- “The requested authorizations cover dates before the alleged injuring event (or diagnosis). If you believe the condition was pre-existing, please provide evidence supporting this belief and supporting the relevance of the proposed request.”
- “The requested authorizations are irrelevant to the present case and unduly infringe on my privacy. These doctors did not treat me for the condition resulting in my present disability. Please justify, with supporting evidence, the necessity of each additional request.”
Realistically, adjusters may continue demanding the requested information before ultimately denying your claims. Providing timely and fair responses, however, can protect you from allegations of non-cooperation during future litigation and appeals. It also shifts the responsibility of justifying the request onto the insurance adjuster.
Provide Limited Authorizations
Disability insurers often request medical releases covering the entire doctor-patient relationship. However, you can limit the applicable date range on HIPPA release forms and even specify which records doctors should provide. This means, instead of signing releases covering all treatment from birth until the present day, prepare releases starting from the first date you sought treatment for the disabling condition.
You might even request that your doctor not provide and/or redact medical information unrelated to the present disability claims. For example, when you discuss two or three different conditions with your primary care physician during the same appointment. An experienced long-term disability attorney might prepare and submit legally compliant, limited scope authorizations on your behalf.
Retain A Local ERISA Attorney
Even simple responses sent on legal letterhead yield immediate results for disabled claimants. Most adjusters know they’re making unreasonable requests. As such, once they learn you retained counsel, they often immediately process your claim. It’s often beneficial to retain a respected long-term disability lawyer before insurers issue a denial.
Hiring counsel to assist you during the claims process may drastically reduce the likelihood of bad faith denials, as adjusters weigh the risk of denial with the inevitable cost of defending themselves during litigation.
An experienced LTD claims and appeals lawyer can:
- Review and respond to all insurance demands
- Receive insurance calls and letters on your behalf
- Prepared limited scope medical authorizations
- Challenge unreasonable records requests under applicable laws and policy terms
- Appeal unlawful denials
- File federal litigation
Whether you need help filing a claim, responding to insurance demands, or appealing unfair denials connect with dedicated Texas and Louisiana long-term disability lawyers for free.
Regulations Prohibiting Unreasonable Disability Document Requests
Federal law governs most employer-sponsored disability policies. Under the Employee Retirement Income Security Act of 1974 (“ERISA”) and supporting regulations, claims procedures must be reasonable and policy terms consistently applied to all claimants (29 CFR § 2560.503.1). Policies must include clear time frames for filing and reviewing claims generally 45 days and insurance communications must provide claimants with specific information.
For example, denial letters must specifically state the reason why the claim was denied/delayed, cite the applicable policy terms, and specifically describe the additional medical documents needed and why such information is necessary to process your claim. When insurers are merely fishing for evidence of pre-existing conditions, they cannot explain the specific records necessary and the reasoning behind the request. Attorneys might refuse to provide authorizations unless and until adjusters justify their need for additional medical documentation.
Appealing Disability Insurance Denials for Pre-Existing Conditions
By digging through excessive medical records, adjusters frequently claim that the disabling condition developed before your policy’s effective date. They might blame your back pain on a car accident from 15 years ago, briefly mentioned in chiropractic reports.
As a former insurance company attorney, J. Price McNamara knows how to identify pretextual denials and appeal adverse claims decisions. Under ERISA, employer-sponsored disability policies must conduct full appeals upon request.
Retaining counsel for your administrative appeal might force insurers to exclude irrelevant medical evidence and reconsider their decision. While this process often yields the same results, you must participate in an administrative appeal before filing federal or state legal claims.
Future litigation also hinges on the evidence contained in this administrative record. In addition to providing long-term disability claims and appeals support, J. Price McNamara is an experienced ERISA litigator. He’s recovered millions for clients wrongfully denied disability benefits after passionately defending their rights at trial. You might even recover attorney’s fees if long-term disability insures wrongfully denied your claims.
Protect Your Long-Term Disability Claims and Assert Your Privacy Rights
When LTD providers request excessive, irrelevant, and comprehensive medical records, this often signals their intention to deny your claim. Adjusters often pressure disability claimants into providing unreasonable access to medical records by taking advantage of their financial situation.
Do not let adjusters bully you into providing unlimited access to personal, private, and irrelevant medical documentation. Bring your concerns to an ERISA long-term disability law firm as soon as possible so they can protect your rights.
Following graduation from Loyola Law School in New Orleans in 1990, Price McNamara served as a Federal Judicial Law Clerk to the Honorable John M Shaw, Chief Judge, United States District Court Western District of Louisiana.
Mr. McNamara founded the Law Offices of J. Price McNamara, and began putting his past experience to work for the injured and disabled clients he now represents against the insurance companies in personal injury and long term disability and other insurance disputes in both federal and state courts