Finessing a Claim with Enhanced Doctor Statement, Job Description to Help Client Secure $15K in Monthly Benefits

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The Challenge

A family physician who saw patients in a hospital clinic and the emergency room suffers from an immunodeficiency disorder, which adversely impacts the body’s ability to produce antibodies. The physician was constantly exposed to pathogens at work, leading to regular viral and bacterial infections and accompanying fatigue and malaise.

Naturally, the physician’s concerns were exacerbated by the pandemic, an event that prompted the physician’s doctor to recommend that the physician stop working and receive immunoglobulin replacement therapy to reduce susceptibility to infections.  

The physician, who was eligible for a monthly benefit of $15,000 under a long term disability insurance policy, submitted a claim. But the claim was denied by the insurance company.  The insurance company concluded that the immunoglobulin therapy would resolve all of the doctor’s current infections and symptoms by a date before the expiration of the policy’s waiting period.  Thus, it refused benefits.

The Solution

The physician came to Schwartz, Conroy & Hack PC after the initial denial, and we got to work re-engineering the claim. We realized we needed to address the insurance company’s misunderstanding of the fact that, despite the impacts of the treatment, the physician’s constant exposure to infections at work would continue to render the physician sick and unable to perform the duties of the job. We took a two-fold approach to accomplish this.

First, we enhanced the physician’s job description, emphasizing the level and the extent to which the physician was constantly exposed to bacterial infections and viruses as a family physician in the hospital clinic and ER. We also worked with the physician’s treating doctor to prepare a rebuttal narrative that addressed the insurance company’s misunderstanding of the exposures and the limits to the treatment’s impact. The doctor explained that by returning to work in the hospital clinic and ER, our client would continue to face constant risk of exposure to viruses and infections, which would continue to adversely impact our client’s health and thus render our client unable to perform the duties of the job.

Armed with this new information, we sent a detailed letter to the insurance company requesting reconsideration of its denial.. 

The Result

The insurance company reversed its prior determination and began paying our client the full $15,000 monthly benefit, which it continues to pay to this day. By re-engineering the claim, Schwartz, Conroy & Hack was able to make sure the insurance company gained a clear understanding of how our client’s disability was preventing our client from performing the duties of the job, and we were able to ensure that the insurance company kept the promises it made to our client.

Evan-SchwartzEvan S. Schwartz
Founder of Schwartz, Conroy & Hack
800-745-1755
ESS@schlawpc.com

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