Sooner or later, most physicians encounter this moment. A patient arrives at an appointment carrying a thick envelope of disability insurance forms. They look uncomfortable when they ask the question.
“Can you help me fill these out?”
For many clinicians, the request lands at the worst possible time. The waiting room is full. The schedule is already behind. And the forms themselves are long, repetitive, and often confusing. Still, you try to help.
The questions ask things like:
- How long can the patient sit?
- Stand? Walk?
- Can they concentrate?
- Can they work full time?
You answer honestly based on your clinical judgment. You complete the paperwork. You send the records. You assume the documentation will explain the situation. Then the claim is denied anyway. A few weeks later another form appears asking nearly the same questions. Sometimes an insurance company physician requests a phone call to “clarify” your opinion. Occasionally you learn that the claim was reviewed by a doctor who never examined the patient.
For many physicians, this is baffling. The diagnosis is well documented. The patient has been treated appropriately. The chart reflects months, or sometimes years, of symptoms and limitations. Yet the insurer concludes the patient can work. For physicians, the experience can feel like being asked to complete paperwork for a system that is using your own medical records against your patient. Why does this happen so often? The answer is uncomfortable but important: Disability insurers read medical records very differently than physicians do.
Disability insurers are not evaluating medical care
When physicians document care, the goal is clinical communication and continuity of treatment. Chart notes record diagnoses, medication changes, symptom updates, and treatment plans. Disability insurers, however, are looking for something else entirely. They are trying to determine whether a person can sustain full-time work. This means the insurer is not primarily evaluating the diagnosis or the quality of treatment. Instead, reviewers scan the records looking for evidence about function.
- Can the person sit for long periods?
- Maintain attention?
- Follow a schedule?
- Use a computer consistently?
- Show up reliably day after day?
If those limitations are not clearly described, insurers often assume the patient can work, even when the underlying illness is serious.
Routine medical language can be interpreted very differently
Many physicians are surprised to learn how closely insurers analyze everyday chart language. Phrases that are completely appropriate in clinical documentation can take on very different meanings in the disability claims process. Consider phrases such as:
- “Patient is stable.”
- “Doing well with medication.”
- “Managing symptoms.”
In medical practice, these phrases often describe a chronic condition that has not worsened. But in a disability claim, they may be interpreted to mean the patient has improved enough to return to work. Similarly, a brief note stating “patient reports feeling better today” may be cited as evidence that the patient’s condition has resolved, even if many other notes document ongoing limitations. Reviewers may focus on isolated sentences rather than the broader clinical picture. To physicians, the record shows a patient struggling with a chronic condition. To the insurer, the same record may appear to show someone capable of returning to work.
The reviewing doctor often never sees the patient
Another surprise for many physicians is how these claims are evaluated. Disability insurers frequently rely on physicians who conduct what are known as paper reviews. These doctors analyze the medical records but never examine the patient. Without seeing the patient in person, the reviewer’s understanding of the illness is limited to what appears in the chart. Nuances that are obvious in the treatment relationship, fluctuating symptoms, fatigue after activity, cognitive slowing, or the cumulative toll of chronic illness, may not be captured in routine notes. The result can be a report that appears objective but fails to reflect the patient’s day-to-day limitations.
Even careful documentation may not address what insurers want
Many physicians assume that thorough documentation should be enough to support a disability claim. Unfortunately, clinical records are not written with disability evaluation in mind. Most notes focus on diagnosis, treatment response, and medication management. They are designed to support patient care, not to assess work capacity. As a result, the chart may document severe migraines, chronic pain, autoimmune disease, or neurological impairment for years. But if those notes do not clearly describe how symptoms affect concentration, stamina, or the ability to maintain a work schedule, insurers may argue the patient could still perform a sedentary job. From the physician’s perspective, the patient is clearly ill. From the insurer’s perspective, the records may not clearly address work capacity.
Small clarifications can prevent big misunderstandings
Physicians should not feel pressured to write lengthy reports or act as advocates in disability claims, especially when they are already managing heavy clinical schedules and large volumes of administrative paperwork. However, small clarifications in routine documentation can sometimes prevent medical records from being misunderstood. For example, a note that states: “Patient reports chronic fatigue” might also include: “Fatigue limits sustained activity and requires rest breaks throughout the day.”
Instead of simply documenting chronic pain, a brief description of how pain affects sitting, standing, or concentration can provide helpful context. These additions do not require speculation about legal standards. They simply connect medical symptoms to the patient’s functional experience.
Why physicians should know this
Disability claims can be one of the most confusing experiences patients face when illness prevents them from working. Many patients turn to their physicians for guidance, even though the insurance system operates outside the normal framework of medical care. Understanding how disability insurers interpret medical records can help physicians avoid unintended misunderstandings in documentation. The goal is not to change clinical practice or turn physicians into legal advocates. It is simply to recognize that the same chart note may be read very differently by an insurance reviewer than it is by a treating physician. And sometimes, that difference in interpretation determines whether a patient receives the financial support they need when illness takes away their ability to work.
Jennifer Hess is a partner at Riemer Hess LLC, a New York City-based law firm with a national practice focused on ERISA long-term disability and disability insurance claims. The firm represents professionals and executives in disability claims, administrative appeals, and federal litigation involving denied or terminated benefits.
Her work focuses on building strong claim records, addressing common insurer defenses, and litigating cases in federal court when necessary. A significant portion of her practice involves physicians and surgeons, where disability determinations depend on a detailed understanding of occupational demands such as procedural skill, cognitive function, fatigue, and patient safety, and how medical conditions affect the ability to perform them.
Hess writes and lectures on disability law and is the author of ERISA Disability Claims and Litigation, An Employment Attorney’s Guide to ERISA Long Term Disability Claims, and A Personal Injury Attorney’s Guide to TBI LTD Claims. Her work has been published by the American Bar Association, New York State Bar Association, American Association for Justice, and U.S. Pain Foundation. She is also a Lawline faculty member and a preferred attorney with the Brain Injury Association of America. More information is available on LinkedIn and Facebook.
