If your ability to practice medicine has been or is starting to become adversely impacted by an accident or an illness, it may be time to submit a long-term disability insurance claim. But keep in mind that when insurance companies receive disability claims, they approach them like detectives investigating a criminal conspiracy. They conduct medical reviews, medical and functionality examinations, financial reviews, field interviews and surveillance, among other things, in an effort to limit their liability. Because of the intense scrutiny your claim will receive, it’s imperative that it be submitted correctly. Here are 10 things to do before filing your claim.
1. Read your policies and understand your coverage
Insurance companies sell different types of long-term disability policies, with various levels of coverage, definitions and exclusions. Most doctors buy individual disability income (IDI) insurance policy, which provides a monthly payment or a lump sum if you become disabled. Some physicians with partners purchase disability buyout insurance (DBO), which is used to fund the buyout of a partner in a practice in the event he or she becomes disabled. Private practitioners also buy business overhead expense (BOE) insurance, which helps cover ongoing business operating expenses when principals become disabled. Group long term disability insurance policies, such as those obtained through a professional association or employer, are less common among doctors than individual policies. Many doctors in practice groups or working in hospital settings often have group coverage. Whatever the type, if you do not have a copy of your policy or policies, get them from your insurance broker or insurance company, and read them carefully to make sure you bought the coverage that you think you bought.
2. Check the definition of disability
Most insurers sell “own occupation” coverage, which defines disability as an inability, due to illness or injury, to perform the material and substantial duties of one’s specific job. This means you will be entitled to benefits if your disability prevents you from performing the duties of your current job. But other policies define disability as the inability to perform “any occupation.” The term “any occupation” is typically defined as any job for which the individual is reasonably suited based on education, training or experience; income usually has to be somewhat comparable as well. So, if you are a surgeon with an “any occupation” clause who can no longer perform surgery due to carpal tunnel syndrome, for example, you would not have to worry about the insurance company saying you can sit and take tickets at a movie theater and therefore able to work. But you may be expected to fill another physician position that does not require the same physical demands.
3. See if you are eligible for residual or partial disability
Some policies include coverage for “residual” or “partial” disability, which kicks in if you have a loss of income because you are either limited in performing one or more of your job duties or if you can only perform them for a shorter period of time because of your disabling condition. Many policy holders don’t realize they have this coverage in their policies. If you do have it, make sure you understand how you qualify for the partial disability, both medically and financially. Many physicians believe that their long term disability policies protect them if they are no longer able to practice in their specialty. This is not necessarily true. Insurance companies may successfully attempt to classify a physician as having a dual occupation . For example, If an orthopedic surgeon performs surgery 90% of the time but is a paid consultant with an artificial hip manufacturer, a insurance company may argue that the physician is not “totally disabled” due to the fact that she can still perform the consulting job. Typically, eligibility for residual or partial disability ends when you reach age 65.
4. Consult an experienced attorney
As early in the process as possible, consult with an attorney who concentrates in long-term disability insurance law. An attorney who practices regularly in this area can advise you regarding the steps to take before, during and after your claim is filed, so that you can avoid the missteps and pitfalls that typically lead to claims being denied, delayed or challenged.
5. Get a diagnosis
To successfully file a long-term disability claim, you must have some type of disabling injury or sickness and the proper medical support to substantiate it. You will need a diagnosis from a qualified doctor who specializes in treating the disabling condition. A spinal condition, for instance, should be diagnosed by a neurologist or orthopedist, rather than a general practitioner. It’s important to keep in mind that, even if your ailment falls within your specialty, the diagnosis cannot come from you and, typically, not from a member of your family, even if they are qualified to do so Also, consider whether a cognitive element affects your ability to work, which can be caused by the side effects of medication or can be a component of your overall diagnosis.
6. Gather additional medical evidence
Beyond your diagnosis, the insurance company will look for evidence of the disability and its adverse impact on your ability to work. Obtain tests such as MRIs, CT scans, X-rays and lab tests to support the diagnosis and your symptoms. You should also gather evidence, where applicable, that shows you tried interventions recommended by your doctor, such as medication, therapies, lifestyle changes or surgery, to improve your disabling condition. Inquire if your doctor would be willing to advocate on your behalf with the insurance company. This would include providing the information necessary to determine if you are disabled within the definition contained in your policy. The doctor will need to complete insurance company forms pertaining to the diagnosis as well as your restrictions, limitations and prognosis (known as an attending physician’s statement).
7. Collect other documentation supporting your disability
Some disabling symptoms, such as pain, are subjective in nature and cannot be medically measured. Nerve-related problems do not always show up on an MRI, X-ray or CT scan, and when they do, these objective tests fail to capture the magnitude of the pain or other subjective symptoms. Nonetheless, insurance companies will almost always require that subjective complaints be supported by objective evidence. If your disability involves subjective complaints, you will need to bolster your case by collecting collateral evidence, which can include an analysis from a vocational expert on whether you can perform the duties of your job. Additionally, documents detailing a long history of performing a large volume of high-quality work as well as statements from colleagues and others about your activities and abilities before and after your disabling condition can corroborate your subjective complaints. keeping a daily diary documenting your pain and limitations can be extraordinarily helpful.
8. Establish a date when your disability started
In disability policies, the “trigger of coverage” is the moment an injury or sickness began limiting or preventing you from performing your job duties. Identifying the date you became disabled may be challenging because many conditions progress gradually. Consult with your doctor and carefully examine your activity levels over time. Surgeons, for instance, should identify when they stopped performing more difficult procedures or if they started taking longer to perform procedures because of their disabling condition. In addition, partial or residual disability definitions require a drop in income due to the disability to qualify for benefits. A note of caution. We often see doctors modify their duties and change their careers due to a disabling condition, and never consider they might have qualified for long term disability benefits at the time they made that change. If you’re making a career modification due to a disabling condition, that is always the time to evaluate the possibility of obtaining long term disability benefits.
9. Plan administratively and financially for your disability
You will need to address any partners in your practice concerning your impending disability application. Prepare administratively for what will happen to your practice and your patients; this will include arranging for the transfer of care of your patients to other doctors, whether inside or outside the practice. You will also need to gather financial documents. You can expect the insurance company will conduct a financial review to classify you as totally or partially or residually disabled. Unless you are a W-2 employee with an easily determined salary, the insurance company will rely on your tax returns, profit and loss statements, and other financial information. In additions, gather production information, including CPT and RVU reports, etc. Disability insurance companies will always gather financial and production information during the claims process to get a full picture of your occupational duties and your earnings.
10. Beware of under-reporting your symptoms and restrictions
Many doctors underplay and under-report their disabling conditions to their doctors and everyone else. Multiple reasons explain this, including fear of malpractice exposure or risk to license, the desire to be tough and power through, fear of telling partners or supervisors, ego, and sense of obligation to patients, to name a few. While this is common and understandable, it can place the success of your long term disability claim in jeopardy. We cannot underestimate the importance of documenting all of your symptoms, restrictions and limitations in order to maximize your chances of getting paid.
This article was originally published on whitecoatinvestor.com
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Evan S. Schwartz
Founder of Schwartz, Conroy & Hack