Make better insurance decisions by looking for these signs

5 Vital Red Flags for Insurance Adjusters to Look for in Disability Claims

Dec 31, 2018

When you’re evaluating a disability claim, you have a responsibility to do so with integrity. But maybe you’ve noticed some patterns, things that give you pause. Points that aren’t as clear as they should be.

When someone’s truly injured and unable to work, of course, the employee should be compensated. That’s the core function of the business. But the business only runs effectively when it minimizes unnecessary expenses. So, here’s a few red flags you should watch out for.

Reporting of Subjective Conditions

Is the claim centred around a collection of subjective complaints? These are things that cannot be objectively verified in the same way a broken bone can be: headaches, dizziness, pain with no obvious cause, and more. Even conditions that have taken off in the popular consciousness, such as fibromyalgia.

The employee may be genuine, but the subjectivity may give you reason to dig a little deeper. An Independent Medical Assessment can help relieve your uncertainty.

Inconsistency on the Documentation

This might arise in several different ways. If an account of an injury varies between different report forms, it could indicate that the employee's history is unreliable — which means you might need to investigate that story.

There could also be inconsistencies from the doctor. And could be a sign that the claimant may not actually be receiving qualified help. Again, something to find out.

Recovery Time Longer than Expected

You’ll have access to the expected recovery times for various injuries. If an employee's injury is lingering far beyond that, it is possible that they’re in the small percentage that does take longer — but you shouldn’t discount the possibility of secondary gain

A Lengthy Delay Between the Incident and the Claim

This could indicate that the claimant wasn’t actually injured enough to affect their ability to work but is now claiming disability for some other reason. Perhaps their employment or domestic situation has changed.

In any case, you’ll want to confirm that they were actively seeking treatment during this period.

Refusal to Attend an Independent Medical Examination

Many disability insurers now include the right to request an Independent Medical Examination as part of their contract — hopefully, yours does too. If so, your decision probably just got easier.

Refusal to be independently examined, or repeated cancellation of appointments, ultimately, suggests that the employee may have something to hide. If they’re concerned that an independent medical expert might deliver a different opinion to their GP, you should be wary of approving the claim.

Why Independent Medical Examinations?

Any one of these alone may not be a big issue, but when you start to see them show up together, it’s a sign the claim needs a little more investigation. When that happens, turn to Independent Medical Examinations. They’re the best way to swiftly obtain the clarity required to make the right decision.

At Western Medical Assessments, we’ve handled tens of thousands of Independent Medical Assessments, allowing disability insurers to get help they can rely on. Our Medical Director Dr. Roger Hodkinson is always available for a quick chat at 780.433.1191. Or, you can started right now with information just for disability insurers.

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