Navigating Disability Insurance Denials for Surgeons

Surgeons must undergo years of education and training before they can embark on their careers. This demanding profession leads many to purchase individual or private disability insurance policies to protect their financial well-being in the event of an illness or accident that leaves them unable to perform their profession.

Surgeons need to have “own occupation” disability insurance policies. The coverage is specifically written to protect their ability to earn income from their medical specialty. Surgeons usually own multiple private disability insurance policies, association policies from organizations like the AMA and, if they are part of a hospital system, also have group policies through their employer. Surgeons are often advised, correctly, to own multiple policies to ensure full replacement of the surgeon’s high income if they become disabled.

Surgeons may even have sub-surgical specialties, and those are often considered to be their occupation, subject to potential challenge by insurance companies, with arguments set forth to support a diluted occupation.  

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Why is Own Occupation Disability Insurance So Critical for a Surgeon?

Own occupation refers to the policy underwriting a person’s ability to perform the specific tasks and duties of the profession for which they have undertaken extensive training and education. This is highly desirable for surgeons, radiologists, anesthesiologists, and others who require financial protection for their unique profession. 

Disability insurance companies seek to deny these claims even when it is quite apparent to anyone, including the surgeon’s own treating physician, that the surgeon is unable to perform their occupation. Common reasons for disabilities include:

Denying the severity of the disability. The disability insurance company may determine that the surgeon’s disability is simply not severe enough under the terms of the policy, regardless of medical evidence to the contrary, and irrespective of the detailed work involving patient safety.

Failing to meet policy requirements. This is where the disability insurance company attempts to deny the claim based on not meeting claim deadlines, not reporting the claim on a timely basis, or failing to seek regular or appropriate medical care or treatment. The terms of the policy may be skewed in an attempt to deny the claim.

Pre-existing conditions not disclosed when applying for the policy or those excluded from the policy. If a policy was purchased after a condition was diagnosed, there is a tough battle ahead, but these are not impossible to overcome.

Ambiguities in the policy language are designed to give insurance companies wiggle room in denying a claim. This is where reviewing a policy carefully before buying can be helpful, but again, this is an obstacle that an experienced disability insurance attorney sees on a regular basis.  Often arguments support considering ambiguous policy terms in favor of a claimant.

Can I File for Part Time or Residual Disability Insurance Benefits?

Some surgeons are able to work in a part-time capacity, if it does not pose any kind of threat to their patients or their own well-being – but it needs to be moderated or limited. Residual coverage provides a smaller benefit to policyholders who can still work, but just not at full capacity. However, whether or not this is an option depends on the language of the policy and the insurance company’s assessment of the surgeon’s ability to work.

Reviewing the policy with a skilled disability insurance attorney can help the surgeon understand whether or not residual coverage is included and whether or not they meet the criteria for eligibility. Navigating the claims process for residual coverage can be tricky, as the insurance company would always prefer not to pay the claim at all.

How Will My Post-Disability Activity Impact My Claim?

Many surgeons play golf on their days off.  Many ask if golf can still be played after they file a claim for disability insurance benefits.  While it is varying depending upon the medical condition – some surgeons who do not maintain fine motor skills any longer due to a condition may still be able to golf.  The theory is that hitting a golf ball poorly is not evidence of ability to perfectly perform surgical procedures with lives at stake.  Our clients navigate these issues through that dissection of the differences between lives and inanimate objects.

Facing a Disability Claim Denial With the Help of a Disability Insurance Attorney

Facing a disability insurance denial is overwhelming for surgeons who are already struggling to cope with health challenges. Assistance from an experienced attorney who focuses their practice on disability insurance claims is invaluable. Jason Newfield has represented many surgeons  – of all specialties – who have needed help navigating claims before filing, after a denial or when it is necessary to take the insurance company to court. 

Jason Newfield can help navigate disability insurance denials for surgeons under “own occupation” policies, which is complex and challenging. Understanding the intricacies of the policy terms, exploring options for working on reduced basis and securing the financial protection from their policies are all familiar issues for Jason Newfield.

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