When Mild Doesn't Mean "Mild"

Many of our clients have claims denied because the insurance company will assert that there’s no objective evidence supporting any restrictions and limitations. This is often confusing because often one or two treating doctors are asserting that there are functional restrictions and limitations for the patient, and the patient, as well as co-workers, all have verified restrictions and limitations. Accordingly, it is necessary to look at the claim record to try to figure out what the insurance company is really saying.

Frequently, we find when reviewing the claim record that this boilerplate comment is made when X-rays or other diagnostic tests reflect mild loss of disk space or mild nerve impingement, or some other use of the term “mild” or even “minimal”. For example, if a client had an X-ray that showed mild loss of disk space, the insurance company may take that to mean the loss of disk space in the back is not very significant and so there must be no significant problem. This is a complete misapprehension of what the term “mild” means in the medical context.

“Mild” in the medical context refers to the degree or measurement of the loss or change and does not correlate to the level of pain or loss of functionality. For example, one patient with mild loss of disk space may have much greater levels of pain and loss of function as opposed to another patient with severe loss of disk space. In fact, even the degree or measurement utilized by the person reading the X-ray, usually a radiologist, is not standardized. This means that one radiologist may think that there is a mild loss of this space, and another may call it a minimal loss of this space, and yet a third may call it a moderate loss of disk space. The comments, therefore, are a subjective interpretation as to what is viewed in the film.

So the next time you or someone you know has a claim denied for lack of objective proof, remember that it may well be that “mild” does not mean “mild” in this situation. Obtain an attorney experienced in employee benefit litigation.