Physicians depend upon disability insurance to replace their six-figure incomes if they become unable to work due to a sickness, accident, or injury. Ironically, the very same high-income levels they bought to protect their lifestyles are the reason long term disability insurance companies try not to pay on their claims.
If you are a surgeon, internist, oncologist, orthopedist, cardiologist, gastroenterologist, neurosurgeon, or any other type of physician, and need to file a disability insurance claim, you will want to protect your disability insurance claim with the help of an experienced disability insurance attorney. There is simply too much at stake to try and do this on your own, with the minefields of the claim process so vast.
Here are the top reasons physician’s disability insurance claims are denied and some of the strategies used by Newfield Law Group to prevent pitfalls during the claim process. You are invited to contact Jason Newfield to discuss your long-term disability insurance claim and learn how you can protect yourself, your family, and your lifestyle, or learn more by visiting our website at www.newfieldlawgroup.com.
Own Occupation and Any Occupation Provisions
Disability insurance policies most regularly define “own occupation” as the primary duties and tasks of your specific medical training. For instance, a surgeon with a hand injury can no longer perform surgery, which is their own occupation. They have undergone specific training and education for this exact occupation, and have received a specialty designation. However, the surgeon may still be able to see patients, diagnose conditions, and formulate a treatment plan. This would be more akin to the ability to perform “any occupation.”
When you purchase LTD insurance with an “own occ” policy, you are most often insuring the income from your own occupation. This is what the policy is typically intended to protect, and surely marketed to doctors as protection. If you had an “any occ” policy (unlikely for a physician), you would face a challenge from the insurance company, which would say that under that scenario, you could work in many different capacities, even if you could not perform surgical duties.
Some LTD policies have limitations on how long benefits will be paid for “own occ” and then switch to a new definition for “any occ.” – much less generous to the claimant, and often an opportunity to terminate benefits. In most cases, these are ERISA policies, group LTD policies from an employer, and there is usually a 24-month period on “own occ,” at which point a claim will be reviewed and possibly denied at the transition definition stage.
Jason Newfield offers a free consultation of your LTD and disability insurance coverage and policies to learn whether or not there are limitations in the policy regarding this issue. Once you understand the policy definitions, key terms, and time limits, you will be able to plan proactively for a termination, if there may be an issue with job performance, or simply determine the timing of a claim.
Documenting the tasks and duties of your profession requires the skilled help of an occupational expert who has experience working with disability claims and understands the assignment, building robust support for your claim. Jason Newfield has access to a network of high-level occupational and vocational experts he works with in creating the necessary support to withstand challenges from insurance companies and to support the claim from inception.
Insufficient or Inconsistent Medical Documentation
As a physician, in many cases, you probably know more about your condition than almost anyone else. However, how your condition is documented and presented to the disability insurance claim is something few physicians know well. Long-term disability insurance companies are seeking specific types of evidence for specific types of claims, and unless you also practice disability insurance law, you are not likely to be familiar with how this works or the nuances of the process.
As an example, for many years, patients suffering from Chronic Fatigue Syndrome were denied claims from disability insurance because of a lack of medical evidence. There was no single test identifying a virus or diagnostic image to prove their illness. Self-reported symptoms of fatigue, headache, nausea and muscle and nerve pain were dismissed by LTD companies and their reviewing doctors as unsubstantiated.
Today, there are a number of tests used to identify Chronic Fatigue Syndrome and related conditions. Newfield Law Group prepares medical documentation with an eye to showing objective evidence from a variety of sources so the disability insurance company is compelled to accept the claim.
Medical treatment reports, evidence of consistency in reporting from provider to provider, proof of ongoing medical care, and critical diagnostic test results are assembled by the Newfield Law Group team to ensure that this is done right from the start. Jason’s decades of experience in determining which tests and studies are required, along with supporting documentation, have led insurance company claims examiners to thank him for making their decision easier.
We do not expect doctors to be disability insurance experts. We know physicians are busy and expect their staff to handle requests for reports and records for patients’ insurance claims. No matter how good the staff is, they are not disability insurance experts. By managing the request for records, making sure the correct diagnostic tests are done, and keeping the documentation in order, we are able to streamline the process for the insurance claims adjuster as well as to prepare for any future challenges.
Policy Exclusions and Pre-Existing Conditions
Almost every disability policy contains specific exclusions and waiting periods for pre-existing conditions. Some plans also exclude certain causes of disability, such as mental health conditions or substance abuse, unless specific riders are purchased. A careful review of the disability insurance policies by a skilled disability insurance attorney will identify the specifics required for the claim to be successful.
Pre-existing conditions are of particular concern for long-term disability claims. If the policy was purchased after a diagnosis, there will be many challenges to a claim, but this doesn’t mean there are no potential strategies or solutions. If you purchased a disability insurance policy and shortly thereafter found yourself with a disabling condition, talk with disability attorney Jason Newfield.
Waiting periods may also delay claims. A thorough understanding of the policies is necessary to understand when benefits will be paid, so financial planning can be done.
Surveillance and Activities That Contradict Disability Claims
Surveillance is an inexpensive way for insurance companies to challenge disability insurance claims. The days of an investigator parked down the street from your home may be gone, but it’s easy to park a vehicle near your home with a digital camera operating from inside the car to track your comings and goings. If you live in a private community, a drone can easily be tasked to survey activity outside of your home.
If you are applying for disability insurance or are on claim (being paid), expect to be monitored once you leave your home. Keep in mind how your day-to-day activities might appear to an outside observer or to an insurer’s investigator. Maintain careful records of when you go to doctor appointments and for treatments, as you may need this in the future to protect your claim.
Jason Newfield tells clients to limit their use of social media or stay off social media altogether. You may make it out of the house once a year for a wedding, but any posts containing photos, including your dancing, standing, or socializing, can be used to demonstrate that you are not actually disabled. Clients are also told to ask family and friends not to post photos with them to avoid the photos being used to deny claims.
Surveillance also includes “field visits,” where an investigator comes to your home, often unannounced, and asks if they might speak with you about your claim. This is a time when you need an experienced long-term disability insurance attorney to protect your interests. Here is what you need to know about these issues:
- You may not be required by your policy to allow the field visit to take place. Review your policy before the knock on the door comes.
- Never allow anyone to enter your home unless you know who they are, they can document their identity, and you have at least one person to serve as a witness.
- If possible, record the visit. Field investigators are notorious for writing up reports that don’t accurately reflect the conversation they had with you.
- If you receive a letter summarizing the visit, read it carefully. Do not assume it is accurate. Show it to your disability insurance attorney immediately.
If a physician claiming total disability is seen working part-time, participating in physically demanding hobbies, or engaging in other activities that seem inconsistent with the claimed disability, insurers may use that as grounds for denial.
Missing Deadlines and Procedural Errors
This is another example of how an experienced disability attorney can take the burden of the process of disability claims from you and ensure deadlines are not missed and procedures are followed. There are strict deadlines with disability claims that, if missed, could mean you permanently lose the ability to fight against a claim denial. There are certain procedural steps that the layperson does not know about. An attorney is needed to protect you from losing millions of dollars in benefits because of a simple and highly expensive error.
Claimants are often surprised by having to maintain their claim – filing regular reports about condition and treatment –with the insurance company. This becomes tedious over time, but missing a report could doom a claim. An attorney taking on this task allows you to focus on your health and not on an overwhelming and complex process.
Changes in Specialty or Partial Disability Confusion
Physicians sometimes shift specialties or reduce hours due to a medical condition, believing it qualifies them for partial or total disability benefits. Obtaining residual benefits can be complicated and requires the help of a skilled attorney. If the policy doesn’t cover partial benefits, or if the insurance company believes your being able to work in a limited capacity means you are simply malingering, the claim may be denied. Timing of claims is important – often, filing a claim before fundamental practice changes occur is an appropriate strategy.
You may need to prove the specialty change was a direct result of your disabling condition. A review of your policy will reveal whether it allows for partial or residual disability coverage, allowing reduced hours while receiving benefits to compensate for lost income.
If policies allow for partial disability, you will need to prepare a complete dossier of evidence that shows how and why the medical condition forced a change in specialty or a decrease in work hours. How the disabling condition causes a loss of income can be challenging at times.
Physicians, despite their medical acumen, are not immune to the complexities of disability insurance. From policy nuances and pre-existing condition clauses to the importance of thorough documentation and consistent activity reports, there are multiple reasons a doctor’s claim might be challenged or denied. Awareness of these common pitfalls—and taking proactive steps to address them—can greatly improve the odds of a successful claim.
