It is not uncommon for a disability insurance company to order a peer review during the long term disability appeal process. If your insurer has requested a peer review, you may have received a letter that states something like:
We are writing to update you of the status of your appeal request for the above referenced Long Term Disability (LTD) claim. After completing our review of your appeal, we have concluded that an adverse benefit decision on your claim is warranted. We have reviewed your complete file in its entirety, including all comments, documents, records and other information received during the appeal, without deference to the decision you appealed. The purpose of this letter is to allow you an opportunity to respond to new evidence and/or new rationales we considered, relied on, or generated in reaching our appeal decision, before we issue our determination.
Such a letter signifies that the insurance company will uphold its decision to deny your claim unless you can convince them with additional evidence or a different argument that proves the peer review doctor’s assessment to be unreliable or incorrect. Therefore, it is crucial that you take action to respond substantively to the report and not disregard the report. This article provides an overview of how claimants can effectively respond to these reports.
What is a Peer Review Report?
In the context of LTD appeals, a peer review report is a document prepared by a medical professional hired by the insurance company. This medical expert reviews your medical records, physician’s opinions, and other pertinent documents to form an opinion on whether you are genuinely “disabled” per your LTD policy’s terms.
The peer reviewer’s role is to be impartial and provide an independent medical viewpoint. However, critics often point out that the insurance company hires the reviewer, which might tilt the opinion toward denying the claim.
The Impact of Peer Review Reports
A negative peer review report can support the insurance company’s rationale for denying or terminating your benefits. Often, these reports may contain inaccurate information, misinterpretations, or outright errors that could unfairly prejudice your case.
Your Right to Respond
Obtaining the Report
The first step in responding to a peer review report is obtaining a copy. ERISA claims regulations were amended in 2018 to require that disability plan administrators provide claimants with copies of any new evidence generated after the appeal is submitted. If your insurer intends to use a peer review report to uphold the denial or termination of your benefits, they should provide you with a copy. If they do not, you should request a copy.
Reviewing the Report
Once you’ve received the report, review it carefully. Take note of any incorrect information or assumptions that you believe are incorrect. It’s highly beneficial to review this report with your treating physician and even consider hiring a legal expert experienced in long term disability claims to dissect the report’s findings. You also need to take note of your deadline to respond to the peer review report.
Requesting an Extension
ERISA regulations require that disability plan administrators provide claimants with a reasonable opportunity to respond to new evidence before issuing an “adverse determination” on the appeal. However, the given timeframe usually doesn’t allow much time. You may find it challenging to schedule an appointment with your doctor or consult with an attorney.
For this reason, we recommend that claimants request an extension as a precaution. Most insurance companies will agree to a 30- or 60-day extension, and you can always submit your response sooner if you do not need the full extension.
Submitting a Response
After a thorough review, you can submit a formal response to the peer review report. In this response, you can:
- Point Out Errors: Highlight factual inaccuracies and misunderstandings about your medical condition.
- Submit Additional Evidence: If critical medical tests, expert opinions, or other evidence supporting your case were missing during the peer review process, include them.
- Contradict Opinions: If your treating doctors disagree with the peer reviewer’s findings, their letter or report can be invaluable.
- Make Legal Arguments: Citing cases decided in federal or state court that apply to your case can strengthen your argument. Legal counsel can be beneficial here.
- Give Personal Testimony: Your account of your limitations can also be a powerful tool in countering the reviewing physician’s opinions.
A peer review physician may attempt to contact your treating providers if they have questions. However, calling a claimant’s treating providers and discussing the claimant’s medical information over the phone violates HIPAA (Health Insurance Portability and Accountability Act). A phone call from an outside provider to a medical doctor to discuss a claimant’s medical condition in an unknown setting and without prior authorization constitutes disclosure of protected health information.
In such a situation, this constitutes a compromise of the privacy and security of the protected health information. Claimants may file a complaint against the insurance carrier and the medical reviewer(s) in question.
Peer review reports can significantly impact the outcome of your appeal. However, the appeals process allows for the opportunity to contest these reports, enabling claimants to challenge inaccuracies and present a more comprehensive view of their condition. Understanding your rights and how to exercise them is crucial for anyone navigating the often daunting terrain of long term disability insurance claims and appeals.
It’s often advised to consult with professionals experienced in LTD appeals when preparing your response to a peer review report. A well-crafted, fact-based response can significantly improve your chances of a successful appeal. If you want to schedule a free case evaluation with a long term disability attorney, call Ortiz Law Firm at (888) 321-8131.