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Friday, May 1, 2015

Medical Records: For Diagnosis and Treatment or Vocational Assessment?

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.   
If there is something relevant to your ability to work, whether observed by the doctor or that you report to the doctor, but is not relevant to diagnosis or treatment, there is no reason for the doctor to note it in the records.  For instance, if a doctor has treated a patient for years for spinal stenosis, the diagnosis was confirmed years ago by an MRI, and all treatment modalities have been exhausted, the doctor is probably not going to note on the medical records that the patient winced when climbing on the exam table, since that fact will change neither the diagnosis or treatment.  The absence of a note of wincing, however, will be interpreted by the insurer showing the patient is not experiencing pain.

This can happen with any patient who is has a long-term largely stable condition where treatment options have been exhausted, such as back pain, fibromyalgia, traumatic brain injury, carpel or cubital tunnel syndrome, or chronic Lyme disease.  But, if the doctor has not noted for two years your reports of pain or his observation of you experiencing pain, the insurer is going to use that absence of evidence as evidence that the impairment is absent.  Particularly when paired with ambiguous surveillance, this can be a basis for the insurer to deny benefits that can be hard to attack.  

How do you fight this?  As I have repeated many times in the blog, you need to tell the doctor the things you experience that show you cannot do your job, and make sure he notes it in the medical records.   Explain to your doctor that the insurance company is going to look to the medical records to assess your ability to work, and make sure he writes down anything that will show you can't do your job.  On my website, I have posted an article on this issue.  

No doctor went to medical school to fill out insurance company forms.  But, I have found that most doctors in Connecticut want to help their patients get disability benefits and win Connecticut LTD appeals.  Show respect for their time by offering to pay for their work, and be upfront and ask for what you need.  You are likely to get the cooperation you need to succeed in a long-term disability claim or LTD appeal in Connecticut.

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