Doctors use medical records for two purposes: for diagnosis and treatment. Insurers use medical records to determine if you can do your job. What’s the problem?
If you have undergone a denial and an appeal, you have learned that your medical records are the one thing the insurer really looks at in making the disability determination, especially if there is no surveillance or in-person interview. If the insurer doesn't find evidence in the medical records that you can’t do your job, your claim is likely to be denied.
There are legitimate uses of the medical records by the insurer. Using the medical records to assess the quality of the diagnosis is fine or for direct evidence contradicting a claimed impairment. For instance:
- It may be legitimate for the insurer to question a diagnosis of fibromyalgia if the tender points test is not done;
- It may be proper for the insurer to consider statements in the medical records that directly disprove a claimed impairment. If inability to twist the neck is a claimed disability, and physical therapy records show full range of movement of the neck, using the records to show there is no neck limitation is legitimate.
So what’s the problem?
The problem is that the insurers treat the absence of evidence of vocational impairment as evidence of absence of an impairment: if the medical records don’t say you are impaired, then the insurer will conclude you are not impaired. But, doctors don’t maintain their records to show current vocational impairment. They maintain the records to address two things:
- Diagnosis: whether the conditions by which a disorder is diagnosed are present and what testing is necessary to show it; and
- Treatment: what treatments have been tried, and whether the treatment alleviates the condition and side effects resulting from the treatment.