Medical adviser (insurer or social security)

The term covers two related functions. At the French national health insurance, the medical adviser checks the medical justification for benefits: validating a long sick leave, a therapeutic part-time return, a move into disability. At a life and health insurer, the medical adviser is the mandatory gateway for health data. At underwriting, the health questionnaire and additional tests are sent to the adviser in confidence; the adviser rules on acceptance, extra premium or exclusion, and passes a decision, not a diagnosis, to the commercial team. At claim stage, the adviser assesses the incapacity rate, the date of consolidation, the link between a condition and a possible misrepresentation. This organization protects medical confidentiality, which the insured waives only in favor of this doctor, who is bound by professional secrecy toward the employer. It does not make the medical adviser a neutral referee: the adviser is paid by the insurer. Hence the challenge routes provided by most policies and by case law: the insured may be assisted by his or her own doctor, request a joint medical examination, then a third-party examination. In group protection, the quality and independence of the medical service directly affect claims experience and litigation.