If your long-term disability (LTD) claim has been denied, there’s a good chance that a “peer review report” played a role in that decision. Understanding what these reports are and how they’re used can help you make sense of the denial letter you received—and decide what to do next.
What Is a Peer Review Report?
A peer review report is typically created during the claims or appeals process when the insurance company hires a physician to review your medical records. The term “peer” refers to the fact that the reviewing physician is considered a professional peer of your treating physician—someone in the same or a similar medical specialty.
Unlike an Independent Medical Examination (IME), which requires a physical appointment, a peer review is a document-based evaluation. The reviewing physician never sees you in person. Instead, they base their conclusions solely on the medical records in your claim file. This can speed up the review process, but it also means that important clinical nuances may be missed.
These reports may be called different things by different insurance companies:
- New York Life: “Independent Medical Reviews”
- Reliance Standard: “Independent Physician Review”
- Sun Life: “Peer Review”
- Unum: “Appeals Physician Written Reviews”
- Lincoln National: “Clinical Review Memo”
- MetLife: “Physician Consultant Reviews”
- Prudential: “External File Review”
While the terminology differs, the purpose is essentially the same: to give the insurer a basis for evaluating—or denying—your claim.
These reviewers are usually hired by or affiliated with the insurance company. They’re supposed to be an “independent” third party, but in practice they are often biased in favor of the insurer. It’s not uncommon for a peer reviewer to downplay symptoms, question your doctor’s diagnosis, or suggest that you’re able to work despite your condition.
Peer-to-Peer Communication
Sometimes the reviewing physician may initiate what’s called “peer-to-peer” communication with your treating provider. This usually involves a letter or phone call asking your doctor if he or she agrees with the reviewing physician’s conclusions. The insurance company usually sets a deadline for this response, and your claim may remain pending until a response is received or the deadline passes.
These communications can affect the final report—either supporting or undermining your provider’s opinion. If your physician doesn’t respond in a timely manner, the reviewing doctor’s findings may go unchallenged.
How Peer Review Reports Are Used in LTD Denials
Insurance companies use peer review reports to justify denying or terminating benefits. For example, the report may say that there’s “insufficient objective evidence” to support your disability, or that the restrictions your treating doctor listed by your treating physician are “not supported” by the medical record. These types of statements can carry a lot of weight in the insurer’s final decision, even if your treating physician has been following your condition for years.
In many cases, the insurance company may rely on a peer review over the opinion of your own treating providers. This can be particularly frustrating if the reviewing physician has never met you or misunderstood key elements of your condition.
Why This Matters in an Appeal
If you’re appealing a denial, it’s important to know whether a peer review report was considered in the decision. The insurance company is required to disclose the evidence it relied on, and peer review reports are often part of the claim file.
You don’t necessarily have to refute every point in the report to win your appeal, but understanding the reviewer’s conclusions can help you and your attorney target weaknesses in the denial. For example, if the peer reviewer questioned the severity of your fatigue based on a lack of lab results, your appeal could include additional documentation from your provider explaining how fatigue is clinically assessed.
Also keep in mind that if your case goes to court, the court will likely limit its review to the existing claim file. This means that it’s critical to address any issues with the peer review report during the appeals process—because you may not get another opportunity to add new evidence later.
Not All Peer Reviews Are the Same
Some peer reviewers are more thorough than others. Some may call your treating physician to ask questions, while others may rely solely on paperwork. Regardless of how the review was conducted, it’s important to look at it critically. If the report seems to gloss over complex conditions or misrepresent the facts, it may be worth pointing this out in your appeal.
Don’t Let a Peer Review Report Be the Last Word
Dealing with a denied LTD claim is stressful, and peer review reports can often make it feel like the odds are stacked against you. But those reports aren’t the final word. With the right documentation and a clear appeal strategy, it’s possible to overturn an unfair denial and get the benefits you deserve.
If you’re facing a denial based on a peer review report, consider speaking with a long-term disability attorney. At the Ortiz Law Firm, we help people across the United States fight back against wrongful LTD denials. We’re here to evaluate your case and help you understand your options. Call (888) 321-8131 today to schedule a free case evaluation.
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