We Americans are known the world over for our work ethic. In 2013, 8.3% of workers worked multiple jobs to make ends meet. Furthermore, we’re reluctant to take leaves or vacations. Owning a business or having a job is our way of realizing our very own American dream, but sometimes, ailments and injuries put a damper on that.
Health conditions and injuries that hamper our ability to perform work are called disabilities. To illustrate, carpal tunnel syndrome is a painful condition that stops computer users from typing on keyboards or using fine motor skills. Depending on the severity of the disability, a person may be able to do less work than they did prior to their disability, or they may even become completely unable to do their job. Disabilities reduce people’s capacity to make a living, which is why private and public insurers offer policies that mitigate that risk.
To qualify for disability insurance benefits, workers in California must submit a claim to their private insurer, to the Employment Development Department, and/or to the Social Security Administration.
What is a disability claim?
A disability claim is a request for income assistance made by insurance policyholders. They submit this request under the belief that a physical or mental impairment hinders them from working at full capacity or finding employment. They may also seek income assistance because they have to purchase special equipment or pay for medical expenses to treat or manage their disability.
Submitted claims must go through an approval process. Generally, insurance as a system works by having a large population of policyholders support a small portion of that population. For as long as a substantial portion of that population continues paying their insurance premiums and only a few are granted disability benefits, the insurance system can sustain itself and grow by investing money in vehicles like government bonds.
If the insurance system is loose with disbursing disability benefits, then policyholders will just take money from the system, causing it to collapse. The stringent approval process makes the system stable and sustainable by ensuring that only the persons who meet certain criteria receive the disability benefits.
What medical documentation helps to have disability claims approved?
For a disability claim to be approved, medical evidence must show that the claimant is indeed disabled and that their disability impairs them from doing their job or prevents them from becoming gainfully employed. Some insurers will require the claimant or the claimant’s representative to provide medical evidence, while others like the Social Security Administration can gather the evidence for the claimant to expedite the application process.
The medical evidence can be presented in the following types of medical records:
- Patient history
- Doctor’s reports containing the diagnosis and prognosis of the claimant’s medical condition or injury
- Results of recent tests that assess the extent of the disabling condition
- Records pertaining to the treatment of the disabling condition
The records are firstly used by the insurer to determine if what the claimant has is indeed a disability as defined in the insurance policy. Because insurers view disability with a different lens, they do not ask doctors to declare whether a patient is disabled or not. Instead, they determine this themselves by investigating these primary questions:
- What conditions, illnesses, and/or injuries does the claimant purport to have?
- When did these begin to present themselves?
- How do these impair the claimant?
- What do the medical tests indicate?
- What treatments have the claimant already received, and is the claimant’s condition improving or worsening?
If the assessment proves that the claimant’s condition is a disability, the insurer then uses the medical records to check if the disability is one that is covered by the policy. To illustrate, let’s say that a preexisting condition like congenital diabetes is determined to be the root cause of a claimant’s blindness. If preexisting conditions are not covered in the policy, then disability benefits for blindness will not be granted to the claimant.
If a disability is covered, the insured party may be asked to submit to a physical residual functional capacity assessment. Information such as the claimant’s capacity to lift objects, stand for prolonged periods of time, and remain mentally alert or focused on a task are collated in a form. This, along with other documents, help the insurer make decisions about disability claims.
Specific types of disability claims may require specific types of medical documentation. For instance, a patient may have reached maximal medical improvement. That is, their medical condition is not getting worse, but it is also not improving — and the patient may be said to have a permanent disability. If this is the case, the patient may file for permanent disability claims, for which they must ask their physician to write them a permanent and stationary (P&S) report.
Law firms in Fresno, Sacramento, and San Francisco trust [company_short] to help them gather the medical records their clients need to have their disability claims approved. Send us a question about your specific medico-legal documentation needs or call us at 866-211-7866 today.