Health Care Professionals and Disability Claims FAQ

This is a guide for Health Care Professionals who must interact with insurance companies on disability claims.

If your patient needs to take a medical leave of absence from their job, they may be entitled to short- or long-term disability insurance benefits (STD and LTD). As their treating health care professional, you may need to interact with their insurance provider from time to time. You could be asked for your clinical notes, records and opinions about your patient’s condition and ability to work.

It is important that you understand how to deal with such requests in order to help your patients get the benefits they deserve.

LEARN MORE

DOWNLOAD THE PDF

BACK TO FAQS

What do insurers look for when they read a health care professional’s reports?

Insurance companies are looking for medical evidence that your patient is unable to work because of their disability.

It is important to understand that your patient’s insurer will require medical support in order to assess their eligibility for disability benefits. The require this information both during the application for disability benefits, as well as while they are receiving benefits.

The test for getting these benefits is nuanced and depends on where they are in the disability application process. That said, it boils down to proving to the insurer that your patient needs time off because they can’t perform their essential work duties.

Your reports to the insurer must explain in as much detail the possible nature of your patient’s disability (within the scope of your speciality) and why, in your opinion, your patient can’t work at the present time.

Back To Top

If you believe your patient needs time off work because of their disability, what should you put in your report?

You need to ensure that you are providing proper detail in any report that you submit to the insurance company. Lack of medical support is one of the most common reasons cited by insurers when they deny disability claims.

The following is a good starting point of what you should include in your report:

• Your professional designation
• The length of time that you have been treating your patient
• Your patient’s diagnosis or, if there is no formal diagnosis, a statement that your patient is disabled from working
• An explanation of your patient’s symptoms or conditions that are disabling them from working
• A prognosis, if you have one. If there is no prognosis, you can note that your patient will continue to be evaluated a certain intervals, such as every four or six months, and that you will inform them of a prognosis once it becomes known.

Back To Top

How do you provide information about your patient to the insurance company?

There are generally two ways to communicate with your patient’s insurance company:

• Patient provides authorization: Your patient can give you approval to communicate directly with their insurance company about the disability claim. The insurer will reach out to you when they need further records or documentation.
• Patient does not give authorization: If your patient does not allow you to talk directly to the insurer, they will give you a form to sign, which you will send to the insurance company.

Back To Top

Can a health care professional get paid for providing information to the insurer?

Yes, Health Care Professionals can get paid for providing their patients’ records to the insurance company for the purpose of a disability claim. Who pays you depends on the situation:

• If your patient gives you permission to talk directly to the insurance company, you should be able to invoice the insurer directly
• If the patient doesn’t give you authorization to communicate with the insurer, the patient will likely have to pay for the reports

Back To Top

What should I do if the insurance company ignores my opinion that my patient can’t work?

If your patient’s insurer disregards your written medical opinion and threatens their disability benefits, you should contact the patient ASAP for assistance.

Your patient should be able to follow your professional advice without fear of repercussion from the insurance company. They should absolutely not be forced or pressured to return to work before they are ready.

At Samfiru Tumarkin LLP, our disability lawyers help people in this situation frequently. It is often a matter of putting the insurer on notice of legal repercussions if they continue to disregard the treating health professional’s opinion and advice.

Back To Top

What should I do if my patient’s STD or LTD claim is denied?

If your patient’s claim has been denied for any reason, or they are told their benefits will stop at some point in the future, your patient should reach out to a disability lawyer at Samfiru Tumarkin LLP ASAP for assistance.

The insurance company will likely tell the patient that they can submit an internal appeal, and ask that their health care provider provide new and additional medical information in support of it. Our experienced team generally does not recommend that you or your patient engage in this process. In our experience, appeals frequently lead to immense frustrations and subsequent denial of benefits, leaving your patient without income and a feeling of hopelessness.

Appeals rarely work. Samfiru Tumarkin LLP often sees patients and their doctors spending an inappropriate amount of time trying to persuade the insurer to reverse their STD or LTD denial, only to be continuously rebuffed. We believe that this process is designed by insurers to frustrate health care providers and their patients, causing them to give up on the compensation they are owed.

At Samfiru Tumarkin LLP, we offer free consultations for every aspect of someone’s disability benefits claim, including when it is denied or cut off. Our goal is to relieve our clients’ stress and secure the money they need while they’re unable to work.

Back To Top

When does your patient need legal help?

Your patient should get legal help when they feel that something is wrong with their disability claim. They can also contact our team if they simply have questions about the claim process itself when applying for benefits, managing their claim or interacting with their case manager.

Samfiru Tumarkin LLP is here to provide free advice and legal options for individuals when:

• They feel bullied, pressured or harassed by the insurance company.
• Their insurer makes odd requests.
• Threats are made about their monthly disability benefits.
• Payments for STD or LTD benefits are denied or cut off.
• Any red flags appear in your or your patient’s mind.

Insurance companies must abide by the rights and obligations set out in the insurance contract, also known as the policy. The team at Samfiru Tumarkin LLP can help make sure they are doing just that.

Back To Top

Can a health care professional contact a disability lawyer for advice?

Yes, you are within your right to talk to a disability lawyer at Samfiru Tumarkin LLP for assistance with a patient’s disability claim. We routinely speak with many health care professionals of diverse backgrounds about provide information and advice for general and patient-specific matters.

Is it a breach of doctor-patient confidentiality?

If the patient provides consent, there should not be an issue with discussing patient-specific matters about an STD or LTD claim denial.

• If your questions are general and not patient-specific, there should be no issues regarding a breach of doctor-patient confidentiality.
• If you are seeking advice or information specific to a patient, we urge you to obtain the patient’s consent first, in writing. You should also act within the prescribed guidelines of your professional organization.

Back To Top

Questions? Concerns? Contact Us!

If you are experiencing an issue anywhere in Canada (excluding Quebec) with your patient’s short- or long-term disability claim or their insurance company, we’re here to help. Call our team at 1-855-821-5900, email Help@DisabilityRights.ca, or contact us online for a FREE consultation.

You can also post your specific question about disability claims online for a quick answer by a disability lawyer at Samfiru Tumarkin LLP, at MyDisabilityQuestions.com.

As Canada’s most positively reviewed disability law firm, we have the experience, tenacity, and determination required to provide the advice you need, and the compensation your patients deserve.