How healthcare insurers are determining your patient's insurance claims

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Written by Haleigh M. The success of any disability claim often lies in the claimants ability to prove he or she is incapable of performing all of dut...

Written by Haleigh M. 


The success of any disability claim often lies in the claimant’s ability to prove he or she is incapable of performing all of duties required by his or her occupation. Often this can be accomplished via medical records and physician statements, but because there is often a great deal of money at stake, insurers generally want even more assurance that the claimant is truly disabled.

This is why many insurers request claimants undergo a functional capacity evaluation as part of the disability claims process. Also known as a functional capacity exam, the FCE is a series of tests, procedures and evaluations designed to determine whether you are physically capable of working and if so, what level of work you are capable of doing.

As a claimant, an FCE can be beneficial to your case — or, as is more common, it can lead to a denial or significant reduction in your benefit amounts. So much hinges on the outcome of this exam, so it is vitally important to seek disability insurance counsel such as the attorneys of Quadrino Schwartz before you see a doctor, to ensure the exam is conducted appropriately.

The specifics of a FCE vary according to the individual circumstances of the case. Someone who works in construction and sustains a back injury will be evaluated differently than a neurosurgeon with an arm injury. Most tests assess either mental or physical capacity to function at work, and attempt to predict whether the patient will be able to return to work, and in what capacity.

The results of the tests are generally evaluated against Department of Labor definitions of occupational standards, which range from sedentary to heavy labor. Your own results will be compared to the requirements of your occupation. In other words, if you work in heavy labor, your tests will assess whether you are able to perform manual tasks, not whether you can work in a sedentary job.

In many cases, you will undergo a functional capacity evaluation before you begin the process of filing a disability claim; most insurers require a doctor’s assessment as part of the claims process. However, it is common for insurers to notify claimants that the FCE results initially submitted are not valid, and you must undergo another examination by a doctor of their choosing.

When this happens, the medical exam is likely to be anything but independent. A doctor that is retained and paid by an insurer has a conflict of interest and therefore the results of the test could be suspect. Never blindly agree to a FCE or any other medical exam without consulting your attorney. Your lawyer will help set the parameters for the exam; for example, your attorney may be able to stipulate that the tests be monitored by a third party,  the physician can only conduct noninvasive tests, or the tests must not be protracted or cause additional pain and suffering.

In fact, the likelihood of FCEs causing more pain and injury leads many disability advocates and attorneys to question their validity in terms of disability determination. Multiple studies have indicated traditional FCEs do not accurately predict whether one is permanently disabled or whether he or she will eventually be able to return to work. Questions of validity are also raised because FCEs do not generally test one’s abilities on an extended or ongoing basis. One might be able to perform specific tasks with a minimum of pain in the short term, but in the long term — such as a day’s work — those tasks or movements could cause debilitating pain. The tests also do not account for pain or other problems arising after activity; for example, some conditions cause extreme pain and fatigue several hours or days after exertion, which a typical FCE will not indicate.

Because the outcome of a functional capacity exam is so important to the overall outcome of a disability case, it’s very important for them to be handled appropriately and that the results are fair and honest. Some unscrupulous individuals will try to make false claims or otherwise take advantage of insurance carriers when they are not actually disabled, and insurers have a right to make sure they are only paying for legitimate claims. However, it’s also important to protect yourself against unscrupulous insurers who act in bad faith to deny legitimate claims. Understanding the FCE process and getting appropriate help is the first step in protecting yourself. 


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