Q: In an ERISA STD claim - is it common practice for the claimants doctor to be listed as a paid vendor in the claim file?
I am the claimant. My employer set me up with the doctor when I had long haul covid. The doctor rescheduled every appointment and then wouldn’t provide office visit notes. The same doctor has lost his license in other states and is noted for accepting ‘more money than. 79% or other doctors for insurance reviews.
It is very common for insurers and administrators for employer provided short-term disability to use 3rd party medical reviewers as part of the claim process. These 3rd party medical record reviewers generally do not have a direct relationship with the insured. They are hired and paid by the insurer or administrator. There are some instances where the insurer or administrator may contact a treating physician to obtain an opinion and, in turn, pay a fee.
In addition, an insurer or administrator may require the claimant to attend an independent medical exam (an IME) for which they pay the physician's fee. As with record reviews, this is also common. If this is an ERISA governed plan (benefits are paid from a trust or insurance policy and not the employer's general assets), the IME notes and opinion should be part of the claim file.
Tim Akpinar agrees with this answer
A: It's standard for doctors to be vendors or contractors in conducting independent medical exams (IMEs), whether for STD, no-fault, workers' comp, or other coverages at the request of the insurance carrier. That's the nature of the industry nationwide. Doctors won't generally provide notes - they'll deliver a narrative report, 2 or 3 pages, and a brief appendix of any supporting materials they were provided with by the claim examiner - films, diagnostic testing results, etc. It won't generally include their notes. Good luck
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