Why do I need "medical support" for my claim and what can my doctors/providers do to help?

Insurance companies regularly refuse to pay for medical care for an injured person because they question whether the treatment is related to the injury or because they think the treatment is unreasonable and/or unnecessary. Judges regularly refuse to pay benefits to disability claimants because they conclude that the claimant’s medical records do not support or match what the claimant is saying. As a result, most of our clients require the support of their medical providers in order to obtain the benefits to which they are entitled. This medical support can take the form of your medical records, completing a form or questionnaire, or a letter responding to questions that we send them. Medical Records Medical records are usually very important to a claim. People should always be honest and thorough when talking to their medical providers. What those providers write down in the chart may be a big deal to a claim. When someone sees a medical provider, it is important to tell each and every medical provider about all medical problems. One way to do that is to simply bring a list of current medical problems and symptoms to each medical appointment and explain, “I want to be accurate about what’s going on with me.” If someone has functional problems because of their medical conditions (such as limitations in standing, lifting, sitting, reaching, paying attention, listening, etc.), it may also help to provide that information to the medical provider as well. Even when the patient is being honest and thorough, medical records can still be inaccurate and/or incomplete. For example, many medical providers do not have the time to talk to a patient about all of the patients’ medical problems, and instead limit a visit to what is most important at that time. Unfortunately, insurance companies, juries, judges, and other decision makers may conclude that if a medical record does not mention a particular medical condition or symptom, then the patient must not have been experiencing that condition or symptom at the time of the visit. Additionally, many computerized medical record systems include routine form entries that can be misconstrued by others. For example: If the history or social section of a patient’s chart note says that the patient is still working (even though the patient hasn’t worked in years), then that person’s disability claim may be denied on that basis alone. Many medical providers do not update this information very often (or at all) because it’s not important to them, but other people may not know that and assume that it’s accurate. If a medical provider writes down “no complaints,” then third parties may conclude that the patient was not having any problems that day. When this problem is pointed out to the patient, the patient may explain, “well, I didn’t tell my primary care physician about my knee problems because I see an orthopedist for that.” But, many factfinders (judges, insurance companies, juries, etc.) do not make those distinctions and may simply conclude that that patient is not credible. If you discover that your medical records are incorrect or incomplete, you should contact the medical provider. Most medical providers have people who can help you with this issue. It is not something your lawyer can do for you, unfortunately. Medical Provider Opinions Regardless of what someone’s medical records say, we sometimes need to get more information or a clarification from a medical provider. That can take the form of a questionnaire or form, or a letter response. Unfortunately, many medical providers are not willing to support their patients by filling out a form or writing a letter for a variety of reasons. REASON #1: “I can’t answer this because I am not an expert/I am not an occupational medicine expert/I don’t know enough.” If a medical provider (a doctor, nurse, physical therapist, chiropractor, etc.) has provided someone with medical care, then under the law, that provider is a medical expert who is qualified to talk about that person’s medical treatment and conditions. It is just that simple. A medical provider does not need to be an occupational medicine specialist or have been treating someone for many years in order to have an opinion about a patient. A medical provider can simply give us their opinion (not a fact – the provider does not even have to be 100% certain) about a patient and their medical care. Additionally, it may be no fault of the patient’s that they have been unable to see an occupational medicine specialist or someone that might be considered more knowledgeable. Occupational medicine treatment is frequently not paid by personal/private health insurance. Many patients lack the resources to effectively navigate the health care system in order to consult with what might be considered the “right” providers. REASON #2: “I don’t want to get involved – I hate testifying.” This is a fair point. Nobody likes being examined under oath; it can be stressful and most people have better things to do. But, it is sometimes part of the job, as an injured or disabled person might need help in obtaining benefits to which they are entitled under the law. If someone’s medical condition or injury requires explanation or clarification, that person’s medical provider is the best (and sometimes only) person to do so. Additionally, the odds of a medical provider having to testify in any given matter are not only slim but also are unaffected by whether an opinion is given or not. Most workers’ compensation and bodily injury claims settle. Social Security and short- and long-term disability claims do not even allow for the actual testimony of a medical provider. Additionally, anybody can subpoena a medical provider. Defense attorneys will sometimes subpoena a medical provider who has NOT given an opinion on the suspicion that the provider does not support the claimant’s case. REASON #3: “I don’t want to tell the truth because then my patient will get mad at me.” We are certainly asking medical providers to tell the truth. It may be that a medical provider says something that does not help a claim. While that is too bad, it is not any worse than the provider refusing to respond. We are obligated to advise our clients of the effects of non-cooperating medical providers on a claim. Sometimes we have to tell people that they have no claim because their medical provider is not responding to questions. REASON #4: “I don’t have time/I don’t like lawyers/I don’t ‘believe’ in lawsuits/I just don’t want to.” There are several excellent reasons for a medical provider to help a patient in a claim. First, we certainly understand that medical providers are busy, and try not to have any last minute emergency requests so that the providers can respond in due course. And, claimants are generally agreeable to paying a medical provider for the time and money in responding to the questions. Surely medical providers try to avoid letting their personal predilections interfere in their care for their patients. It should be undisputed that a medical provider is supposed to help the patient. Answering questions about the patient’s medical condition in an honest and truthful manner can allow the patient to obtain additional medical care and other benefits to which they are entitled under the law. Medical providers are generally supportive of access to medical care (and getting their own facility’s bills paid). Finally, a medical provider who responds to questions about a patient’s functional limitations is complying with the policies of the American Medical Association ("AMA"). Here is a link to the AMA policy on “Impairment and Disability Evaluations:" AMA Policy on Impairments and Disability Evals

Who qualifies for SSI benefits?

[fusion_builder_container type="flex" hundred_percent="no" equal_height_columns="no" hide_on_mobile="small-visibility,medium-visibility,large-visibility" background_position="center center" background_repeat="no-repeat" fade="no" background_parallax="none" parallax_speed="0.3" video_aspect_ratio="16:9" video_loop="yes" video_mute="yes" border_style="solid"][fusion_builder_row][fusion_builder_column type="1_1" type="1_1" background_position="left top" border_style="solid" border_position="all" spacing="yes" background_repeat="no-repeat" margin_top="0px" margin_bottom="0px" animation_speed="0.3" animation_direction="left" hide_on_mobile="small-visibility,medium-visibility,large-visibility" center_content="no" last="no" hover_type="none" min_height="" link=""][fusion_text] SSI pays benefits to people who are (a) disabled and (b) have minimal or no assets/resources. An SSI recipient does not have to have ever worked or paid into the SSA system. Children (under 18) who are disabled can qualify for SSI benefits as well. An SSI recipient’s spouse and/or children do not qualify for additional SSI benefits. Find more information here: https://www.ssa.gov/ssi/text-eligibility-ussi.htm [/fusion_text][/fusion_builder_column][/fusion_builder_row][/fusion_builder_container]

Who qualifies for SSDI benefits?

Disabled adults who became disabled on or before their “date last insured” generally qualify for SSDI benefits. An SSDI recipient’s spouse and/or children are also generally eligible for additional SSDI benefits. Find more information here: https://www.ssa.gov/disability/eligibility

How do SSDI, long-term disability, and/or workers' compensation benefits affect each other?

Many injured workers are eligible for Social Security disability and/or long-term disability benefits in addition to workers’ compensation benefits. However, there are rules that limit how much of each type of benefit you can receive. Minnesota Workers’ Compensation Offset An “offset” is the reduction of a benefit by the amount of another benefit. Minnesota workers’ compensation temporary total (“TT”) disability benefits are not reduced by Social Security disability benefits. Minnesota workers’ compensation permanent total (“PT”) disability benefits are reduced by Social Security disability benefits, but not until after you’ve received $25,000.00 in PT benefits (and only if the PT benefits and Social Security disability benefits are based upon the same injuries). Then, PT benefits are reduced by the amount of Social Security disability benefits. If your workers’ compensation date of injury was before October 1, 1995, then there may “supplementary” benefits available to make up for that offset. Social Security Offset Federal law does not allow injured workers who are also eligible for Social Security disability benefits to receive more than 80% of their monthly average current earnings (“ACE”) in both Social Security (retirement and/or disability) AND workers’ compensation wage loss (TT and/or PT) benefits. The ACE is a figure that the Social Security Administration (“SSA”) calculates by either averaging your highest consecutive 5 years of earnings OR by using the highest year of earnings in the 5 years prior to your disability onset date. So, if you are receiving both workers’ compensation and Social Security disability benefits, and those benefits added together are MORE than 80% of your ACE, then your Social Security disability benefits will be reduced to keep your monthly Social Security disability and Minnesota workers’ compensation benefits at or below 80% of your ACE. In calculating these amounts, the SSA will not only consider how much you are receiving in Social Security disability benefits but will also include any benefits your minor children are receiving as a result of your disability. If you settled your Minnesota workers’ compensation claim on a lump sum basis, then there should be “Social Security” language in the Stipulation for Settlement that breaks down the lump sum into monthly amounts for purposes of calculating a possible potential Social Security disability offset for the duration of your life expectancy. Attorney’s fees should be left out of this calculation. Social Security retirement benefits should not be reduced by workers’ compensation benefits. But, workers’ compensation benefits WILL reduce by any amount of Social Security retirement benefits. Long-Term Disability Benefits Long-term disability (“LTD”) benefits are generally governed by the terms of the LTD policy. Most LTD policies have provisions in the policy that require their insureds to apply for Social Security disability benefits if the insured has also applied with them for LTD benefits. This is because the policies also usually have provisions that will reduce the amount of LTD benefits by however much the insured also receives in Social Security disability benefits. This is a dollar-for-dollar offset, but most LTD policies will pay the insured a little something each month even if the Social Security disability benefit completely wipes out the LTD benefit (usually $100). Many LTD carriers will require their insureds to sign a reimbursement agreement of some sort in which the insured promises to pay back the LTD insurer for any month in which they received both LTD and Social Security disability benefits. That agreement can apply retroactively – meaning, if you are collecting LTD benefits and then later qualify for Social Security disability benefits, any Social Security disability benefit back pay can be counted against you. *Keep in mind that any attorney’s fees you had to pay to someone in a Social Security disability claim should not be counted against you in calculating an offset against LTD benefits. There isn’t any real way around any of these terms. Most people are not aware of them when they sign up for LTD benefits, but the LTD policy ends up being pretty much a sham if you end up qualifying for both benefits (which most do).

Wisconsin & Minnesota | Duluth, Iron Range & Surrounding Northland

The Northland’s Trusted, Award-Winning Legal Team Since 1975

Wisconsin & Minnesota | Duluth, Iron Range & Surrounding Northland

The Northland’s Trusted, Award-Winning Legal Team Since 1975

WI & MN | Duluth, Iron Range & Surrounding Northland

The Northland’s Trusted, Award-Winning Legal Team Since 1975

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FAQs

Why do I need “medical support” for my claim and what can my doctors/providers do to help?

How does a negligence/motor vehicle collision claim work and how long does it take?

What happens in a civil lawsuit in Minnesota?

Who qualifies for SSI benefits?

Who qualifies for SSDI benefits?

How do SSDI, long-term disability, and/or workers’ compensation benefits affect each other?

Talk with our experienced attorney about your rights.