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Proving and Defending Against Claims of Disability Fraud

Over 9 million people receive Social Security disability benefits. Many more are covered under private insurance and workers’ compensation. While most of these cases are legitimate, some are fraudulent. The need to properly evaluate disability claims is necessary to minimize the risks of improper payment as well as to ensure that those who are disabled are paid. Medical expert witnesses provide the expertise to protect both sides.

Disability claims may be submitted to private carriers and/or government entities. Private disability insurance applies regardless of where an injury occurred. Workers’ compensation benefits are available to employees injured at work. A person may also apply for Social Security or other government programs, although the amounts are adjusted for those receiving payment from multiple sources. Regardless of where a claim is filed, there are opportunities for fraud. The most common types of disability insurance claim fraud arise from claimants lying on applications, misrepresenting illnesses or injuries, failing to report work-related income, illegally claiming on multiple policies, and “dead money” schemes wherein the claimant died but family members fail to report it and continue to accept disability payments. Similarly, workers’ compensation claimant fraud typically involves false or exaggerated claims and working while collecting benefits. Although workers’ compensation fraud occurs more often than disability insurance fraud, it only accounts for about 1 percent to 2 percent of all workers’ compensation payments.

The difficulty with disability claims is that there is no diagnosis of “disability.” Various ailments may limit a person’s ability to work. Medical examinations are used to establish a patient’s condition and whether he or she can work, but two patients with similar conditions may get a different determination of disability based on the patient’s or physician’s evaluation of the severity of the ailments.

The difficulty in proving or disproving disability is particularly problematic in cases involving back pain and mental illness. Such claims are among the fastest growing causes of disability. Medical expert witnesses are particularly needed to evaluate these claims to determine the existence and severity of the alleged condition.

For example, applicants who are denied coverage and insurers that must justify their decisions can look to Orthopedists and Orthopedic (“Orthopaedic”) Spine Surgery experts. These specialists treat problems of the cervical, thoracic, lumbar, and sacral spine such as neck and low back pain, disc herniation, spinal trauma (fractures), vertebral infections (vertebral osteomyelitis), and scoliosis and can testify regarding the permanency, treatment, and prognosis of various spinal issues. Neurologists and Pain Medicine physicians also may provide valuable insights concerning the evaluation, diagnosis, and treatment of various types of pain. Where mental illness is an issue, Psychiatrists and Psychologists may be needed to provide medical reports and expert testimony on the diagnosis, treatment and severity of mental disorders.

Such expert testimony is invaluable in ensuring disabilities are properly identified and awarded compensation. If you are involved in a disability case, Elite Medical Experts can help you secure nationally recognized university healthcare experts to support your case. Contact us today for a consultation.

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