April 23, 2001
Insurance Adjuster Letter
Karen Gann and John Fetto, JD
Karen Gann's Question
My onco-doc recently received a "Rehab" form from my private disability company, to fill out about me. How long could I sit, stand, lift, how much weight, etc., etc. He was furious, and had his nurse call me, wondering, "What part of permanently disabled do these people not understand?" He sent it back (after I called the company and talked to them about it), stating that he did not feel qualified to fill it out.
For those who have just tuned in, I'm lung mets since Sept., 1998. On SSDI and private disability insurance since May, 99.
Today, I get a call from a nurse who identifies himself as a case manager for Brand X, hired by my carrier to "meet" with me. I asked him if the company he works for is owned by my carrier - who pays him, who pays them. He assured me that they were an independent company and had no ties, blah, blah, blah. I agreed to meet with him.
A quick check shows that his company is indeed owned by my insurance carrier. They are an independent subsidiary. Yeah, sure I'm going to get an impartial review of my case from this guy.
So, finally the questions. Do I have to meet with this guy? What are my rights in this situation? Can I demand a review from a truly independent firm?
Crazy in Tn, as in "I'm not dying fast enough to suit these people!"
John Fetto, JD replies
I don't know for sure. I don't practice in this area. What I always do in these situations is to first get them to commit in writing to what they want to do. Play dumb. They say they have a right to do an "independant medical examination" to second guess the opinion of your doctor. Can they cite the part of your disability contract that gives them that right? Secondly, ask what is the scope of the examination or interview? Is it necessary, given the fact that you have been diagnosed with a life threatening disease? Finally, remind them that they said in the telephone conversation that they had no affiliation with the diability company. As them to confirm that in writing.Once you get their response, take it to a lawyer who specializes in disability law. The point is get their representations in writing. The letter should read something like this:
Dear Brand X Insurance Adjuster [insert true name]
This is to confirm your telephone call to me in which you requested to conduct an "independent" examination or interview of my medical condition. In conversation I was told you were not affiliated with Brand X. I'm confused. Why is this necessary after my doctor has confirmed that I have a life threatening disease? Please answer the following questions in writing:
Do I have a choice about this interview or exam? Is there some law or provision of my disability insurance which requires me to submit to it? If so, please cite the specific statute or contractual language which requires me to submit to this exam or interview. Given the documentation from my doctor, it seems unnecessary.
What is the scope of the exam or interview? Am I to be examined by a health specialist, like an Oncologist? If not, then by whom? Could you please confirm in writing that these people are not employed by any company or corporation affiliated with the Brand X Disability Company.
I'm sure you understand my concern. If you will provide written answers to the above questions as soon as possible, I will try to act on your questions promptly.