As disability insurance lawyers, we represent a wide range of physicians and other medical providers. Emergency room physicians, who stand in the front lines of critical care, face unique and daunting challenges when it comes to obtaining long term disability (LTD) insurance benefits. Despite the physically and mentally demanding nature of their occupation, ER doctors are disproportionately subject to denials, delays and even termination of their long term disability insurance claims.
The answer is not the legitimacy of their disability, but the economics of disability insurance. Insurance companies are more aggressive about scrutinizing these claims. The ER doctor is a financial liability for a long term disability company whose incentives are not to be fair, but to be profitable.
What Drives the Denials, Delays and Terminations?
Emergency physicians are uniquely vulnerable to disability because of the nature of their work. They have incredibly stressful jobs, which takes a toll on the physical and mental health of the doctor. The profession demands unwavering alertness, making critical decisions under pressure and must have the physical stamina to ensure long, exhausting shifts. A moment of hesitation, even a slight cognitive fog can lead to dire consequences for patients. As a result, many ER doctors find themselves unable to safely continue in their work when they experience physical or mental impairments.
Then why are these physicians often met with a denial letter when filing an LTD claim?
Insurance companies treat any high-dollar claims with heightened suspicion. Long term disability benefits for ER doctors tend to be substantial, usually five-figure monthly payments. Insurers are motivated to avoid these payouts whenever possible. By denying, delaying, or terminating a claim, the insurance company’s profit margins are protected. There is no punitive consequence for a wrongful denial. Unlike a personal injury claim, where bad faith actions may result in damages or sanctions, there’s no downside to the insurance company denying a claim.
The insurance company has nothing to lose. The ER doctor, on the other hand, could be left with no income while battling a labyrinth designed to wear them down.
The Uneven Playing Field: Insurers Have the Advantage
The disability insurance company has vast resources: in-house legal teams, extensive medical consultants and time-tested tactics meant to reduce paying benefits. Disability claimants, even extremely smart medical professionals, are simply not operating on equal footing.
Making matters more challenging, the adjusters reviewing these claims are not medically trained professionals. They don’t have clinical training that would allow them to interpret nuanced medical conditions, especially when it comes to subjective conditions like chronic pain, fatigue, or cognitive issues. In addition, their job performance is likely to be tied to claim closure rates.
As a result, the insurance company’s position is adversarial, especially when it comes to high-value claims. The burden is on the disabled doctor to present a well-documented, robust, and legally sound case to withstand the scrutiny and process designed to thwart their claim.
Medical Documentation: Why Peer-to-Peer Diagnosis isn’t Enough.
ER physicians accustomed to informal consultations by a peer may assume a quick look or professional opinion from a colleague will suffice. This is not the case.
Insurance companies require comprehensive, objective evidence of disability including:
- A complete diagnostic workup by an independent treating physician
- Objective testing including imaging, bloodwork, neurocognitive evaluations
- A clearly outlined treatment plan.
- Consistent documentation of symptoms, impairments, and limitations on the tasks of the physician.
The claim will also need to include an occupational evaluation to explain the physical and mental tasks required of an ER physician. This is a critical piece, as the claims adjuster may not fully appreciate the physician’s need to make split-second decisions, have the stamina for a demanding shift and physical responsiveness under pressure.
The Value of Legal Representation
The stakes are too high for an ER physician to file a claim without legal counsel who has specific experience in long term disability insurance. General legal knowledge will not suffice.
Newfield Law Group works closely with physicians to build legally and medically comprehensive claims files to anticipate insurance company objections. We have experience and understand the nuances of ER medicine and the tactics used by insurance companies to deny and delay valid LTD claims. Our work includes:
- Reviewing and interpreting disability insurance policies, including “own occupation” provisions
- Coordinating with treating physicians to strengthen medical documentation
- Preparing narrative statements and vocational analysis to bring the claimant’s story to life.
Why Emergency Medical Claims Face Greater Risk
In addition to protecting profits, a long term insurance attorney is needed to protect the ER physician.
Higher monthly benefits will draw more scrutiny, as they create greater financial exposure for the LTD insurance company. The younger the physician, the more expensive the claim will be to the company.
Many ER physicians supplement their income with consulting work, medical-legal reviews, or concierge services. While these are dramatically different from the high-stress work in an ER, LTD companies may argue that any ability to work in a related capacity undermines the claim.
Active lifestyles put ER physicians at risk. They often pursue demanding physical activities as outlets from their high stress jobs. The insurance company will use these hobbies against the claim, arguing that the physical activity contradicts claims of impairment.
Surveillance and Social Media: Beware of the All-Seeing Eye
Once a claim is filed, or sometimes, even before, disability insurance companies may initiate surveillance. This includes:
- In person surveillance. Private investigators may monitor your home, follow you in public or photograph you engaging in daily tasks or hobbies.
- Social media monitoring. Disability insurance companies were quick to use social media against claimants. A single post of a vacation photo, even if it was taken before you suffered a disability, can be used to cast doubt on current limitations.
- Activity checks are done when investigators or other insurance company employees contact your office or speak with colleagues to verify your work status.
Filing a long term disability claim is not like filing for a homeowner or car insurance claim. Each monthly benefit is expensive, and over time, extremely more expensive than the above auto or home claim. The process is a high-stakes legal and medical gamble against a profit-driven system. To prevail, it’s critical to work with a long term disability insurance attorney who can protect your rights and knows how to navigate the obstacles unique to your profession.
