Mistakes Physicians Make When Submitting Claims for Disability Benefits

Because of the significant increase in disability claims filed by physicians over the last several years, insurance carriers are now scrutinizing the terms of their policies and any claims made thereunder, utilizing novel and creative theories when denying benefits. Physicians should familiarize themselves with their policies and the claims process.

Because of the significant increase in disability claims filed by physicians over the last several years, insurance carriers are now scrutinizing the terms of their policies and any claims made thereunder, utilizing novel and creative theories when denying benefits. Physicians should familiarize themselves with their policies and the claims process.

The following are common mistakes made in connection with filing a claim for disability insurance benefits:

Mistake # 1 Failing to consult with counsel

Disability provisions vary greatly in the language used, and coverage is often circumscribed and restricted by qualifying words and phrases. Accordingly, each policy of insurance must be individually reviewed to determine whether a particular claim is covered and, if so, how that claim is best presented to ensure payment.

Mistake # 2 Misunderstanding the definitions of “Disability” and “Occupation”

There is no such thing as a “standard” disability insurance policy. Most physicians purchase “own-occupation” policies that provide compensation following a disability that prevents the insured from performing the particular duties of his or her occupation. Thus, the insured may be entitled to benefits even if he or she could in fact perform work of a different nature. The central issue in many cases is the definition of “total disability,” which could variously mean that the insured cannot perform “all” or “every” duty of his or her occupation, or the “substantial and material duties” of his or her occupation.

Similarly, the term “occupation” may be specifically defined in the policy, e.g., “invasive cardiologist,” or may refer to the insured’s occupation immediately prior to the time that disability benefits are sought. In the latter situation, if the physician reduces his or her hours in the months preceding claim filing, the carrier may consider his or her occupation to be part-time rather than full-time. Similarly, the term “occupation” may be comprised not only of the duties of a physician’s specialty, but also significant travel time, teaching engagements or other areas in which he or she spends time or draws revenue. For example, your “occupation” may be defined as “physician/professor/business owner,” in which case you may not be “totally disabled” if you can still teach or perform management functions.

Mistake # 3 Blindly attending an independent medical exam

After submitting your claim, you may be asked to submit to an “independent” medical examination by someone chosen and paid for by your insurance carrier. Before submitting to an “independent” medical exam or any other exam, you must first ensure that your carrier has a right to conduct the exam per the policy language. For example, a neuropsychological exam is conducted over several days by a psychologist, not a physician, and the subjective findings from such an exam are often used by the carrier to deny benefits. If your policy requires that you submit only to “medical exams” or exams “conducted by a physician,” there is certainly an argument that you need not submit to neuropsychological testing. Further, you may wish to be accompanied by an attorney or other legal or medical representatives who can monitor your “independent” medical exam.

Mistake # 4 Believing all mental conditions are excluded or subject to limitations

Most disability insurance contracts differentiate between mental and physical disabilities. More recent policies cut off benefits for psychiatric conditions after 2 or 3 years. Insureds often blindly accept their carrier’s decision to deny or limit benefits based on these conditions without considering numerous relevant factors, including whether there are any physical aspects to the mental condition, whether the mental condition has a biological/organic cause, or whether another, covered condition was the legal cause of the disability.

Mistake # 5 Inadequate communication with treating physician

You should not discuss your claim or that you are considering filing for disability insurance benefits with your treatment provider until after you have had several visits. Physicians are often reluctant to support claims for benefits if they question your motivations. A physician who has treated you without success will likely be more willing to cooperate. It is also important that you communicate your symptoms and limitations to your treating physician in an organized and detailed manner so that all relevant information is recorded in your medical records, which your insurer will ultimately request.

Mistake # 6 Quantifying your time

You should be wary of insurance companies asking you to compartmentalize in percentages what activities you engaged in pre- and post-disability. To the extent that there is any crossover, companies will often deny benefits or provide benefits for merely a residual disability. It is important that you broadly describe your important duties—rather than your incidental duties—so that your carrier has a clear understanding of the thrust of your occupation.

For example, in response to a question about principal duties and the percentage of time spent at each duty, an anesthesiologist may be better off stating “100% surgical anesthesia” rather than compartmentalizing each and every incidental task (e.g., patient intake, supervising nurses during surgery, post-operative visits) into discrete percentages. The reason is your insurer may erroneously consider an incidental task a “principal duty,” and therefore downgrade the amount of your benefits. For example, where a physician has duties as a businessman (i.e., supervising staff, overseeing payroll), the insurance company may argue that the disabled physician can still manage his or her practice, and is therefore only partially disabled.

Insurance companies are vigilant in protecting their own interests, which often means not paying claims. Insureds may often need to be even more vigilant in protecting their own interests by seeking experienced counsel to assist them in submitting their claims for benefits.

* Edward O. Comitz, Esq. heads the Health and Disability Insurance Practice Section at Bonnett Fairbourn Friedman & Balint, P.C., 2901 N. Central Avenue, Suite 1000, Phoenix, Arizona 85012, (602) 274-1100. Mr. Comitz has extensive experience in disability insurance coverage and bad faith litigation, primarily representing medical and dental professionals in reversing denials of their disability claims. For more information about disability insurance issues, please visit our website at www.disabilitycounsel.net.

DISCLAIMER

The information in this article has been prepared for informational purposes only and does not constitute legal advice. Anyone reading this article should not act on any information contained therein without seeking professional counsel from an attorney. The author and publisher shall not be responsible for any damages resulting from any error, inaccuracy or omission contained in this publication.