Termination of long term disability benefits based on false medical reviews.
James C. (The Hartford)
James C. suffered multiple medical problems that were clearly debilitating. All three of his treating physicians agreed that he was totally disabled from performing the duties of any occupation. He had coverage with the Hartford, which insured him from disability from his own occupation and provided for payment of LTD benefits for so long as he was disabled until the age of 65.
The Hartford approved his claim and paid his LTD benefits for more than a decade. It then initiated what it what it called a “Clinical Management Plan”, which was merely a euphemism for setting up the file to terminate his benefits. As part of this plan, The Hartford sent the medical records over to a reviewing doctor, who conducted an oversimplified review of those records, never once examining James. That same reviewing doctor made three separate phone calls to three of James’s treating physicians.
There were copies of three letters in the Hartford claim file from the reviewing doctor to each one of the treating physicians, purporting to confirm the substance of each of their phone conversations. According to the reviewing doctor’s subsequent report to the Hartford, each of the treating physicians agreed with him that James’s was “stable” and thus no longer totally disabled from his own occupation. Each of the letters to the reviewing doctors stated that if he did not receive a response within 10 days he would assume that everything stated in his “confirming” letters was accurate and complete. Then, the very next day he wrote his report to the Hartford. (i.e. He didn’t even wait the 10 days for a response.) After that, the Hartford had its own, in-house vocational consultant prepare a report, stating that given the duties of James’s occupation, as he understood them, and given the reviewing doctor’s medical conclusions, James was suddenly ready to go back to work. Then, based solely upon the reports of the reviewing doctor and the vocational consultant, the Hartford terminated benefits.
After the termination, I personally contacted each one of the treating physicians. Each of them not only denied the alleged substance of the phone conversations, as were related to the Hartford, but each of them emphatically said that his statements to the reviewing doctor were misquoted and distorted in the reviewing doctor’s report. And each treating physician stated that he vehemently disagreed with the reviewing doctor’s conclusions regarding James’s total disability and that James was indeed totally disabled from all work.
But more importantly, each of them emphatically stated, in writing, that he never received any letter from the reviewing doctor, purporting to confirm the substance of their phone conversations. As a result, not one of them had an opportunity to respond to the mischaracterizations of their conversations. Each treating physician stated that the first time he ever saw the mysterious alleged “confirming” letter was when I provided a copy (which I had extracted from the Hartford's claim file). Each then expressed, in writing, extreme outrage over the termination of James’s benefits, as well as over the mischaracterization of their remarks and the fact that their remarks were “confirmed” in a letter that not one of them ever saw.
The clear inference was that the reviewing doctor never sent any one of those letters. And, given the fact that his report to the Hartford was prepared within one day of his alleged conversations with those treating physicians, (rather than waiting 10 days for a response, as he said he would in the letters), suggested that this it was not merely a clerical error. Instead, it suggested that he never had any intention of affording any of those treating physicians any opportunity to respond to his remarks. It raised yet a further inference that he deliberately misrepresented the substance of the treating physician's comments.
To the Hartford’s credit, when I called the facts of this matter to its attention, it immediately reversed the denial and reinstated James’s benefits.