After being denied your long-term disability benefits claim, you may have requested the carrier to produce your entire administrative file. In response, the carrier will normally produce all of the documents it received and relied upon to deny your claim. Usually missing from the production, however, are the carrier's SOAP notes and other internal communications regarding your claim. These missing documents may contain a treasure trove of useful information regarding the insurance carrier's thought process (or lack thereof) that went into the denial of your long-term disability benefits claim. You have a right to the entire administrative record under the Employee Retirement Income Security Act of 1974 (ERISA).
The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by doctors and other health care providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Documenting patient encounters in the medical record is an integral part of practice workflow starting with patient appointment scheduling, to writing out notes, to medical billing. Long-term disability insurance companies also use the SOAP format to track their own internal analysis of the LTD claim.
Subjective component
This describes the LTD claimant's current condition in narrative form. The experienced symptoms are recorded in the claimant/patient's own words. It will include all pertinent and negative symptoms under review of body systems. Pertinent Medical history, surgical history, family history, social history along with current medications and allergies are also recorded. In the disability denial appeal process, I often use affidavits to flesh-out my client's subjective complaints to provide the carrier with details that may not appear in the medical record. Because the subjective complaints are recorded in only a summary fashion in the medical notes, I will also have my client's doctor elaborate on them in a written report.
Objective component
Includes vital signs, findings from physical examinations e.g. posture, bruising, abnormalities, and results from laboratory tests. The objective measurements in the claimant's medical file are not always indicative of the existence of a disability. Some conditions, like chronic pain syndrome and fibromyalgia, cannot be measured objectively. Other conditions, e.g. neurological, show normal functioning when measured in a laboratory setting but may not accurately measure the claimant's inability to function in a full-time job under pressure.
Assessment
Is a quick summary of the claimant/patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. When there is more than one diagnosis, I find it useful to create a record of the interaction of the two conditions and medications for each. The combined total health condition may be more than the sum of the parts.
Plan
This is what the health care provider will do to treat the patient's concerns. This should address each item of the differential diagnosis. A note of what was discussed or advised with the claimant/patient as well as timings for further review or follow-up may also be included. Often the Assessment and Plan sections are grouped together. Most LTD policies require the claimant to be receiving ongoing medical treatment and adherence to a reasonable plan for treatment in order to qualify for long-term disability benefits.
In following the SOAP protocol, the long-term disability carrier often relies on email and other internal communications. Getting copies of those communications is vital to proving your claim for long-term disability benefits. In my experience, those emails have revealed the carrier's influence on its vocational consultant and medical experts. The internal documents are also critical to establishing whether the individuals employed by the insurance company were qualified to deny benefits. Getting the entire administrative file including internal SOAP notes and emails is an important step in winning your claim for long-term disability benefits under ERISA.
Alan C. Olson practices disability law from his offices in New Berlin, Wisconsin, and throughout the United States. AOlson@Employee-Advocates.com
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