The Importance of Regularly Reviewing Your Disability Policy

The new year is often a time for making resolutions and planning for the future.  This should include reviewing your financial situation, including assessing whether you will be adequately prepared in the event that you become disabled and have to stop practicing.  We recommend that you make a periodic review of your disability policies and evaluate:

  • What type of policy(ies) do I have?
  • Do I understand the terms and provisions of my policy(ies)?
  • How much coverage do I have?
  • Do I have enough coverage?
  • Do I qualify for any increase options?
  • Should I buy an additional policy(ies)?

Many physicians and dentists purchase their policies as residents or when they are first establishing their practice, and then file their policies away and don’t think about them again until the unexpected happens and they need to file a claim.  This is problematic, because financial needs and obligations change over time, and the income and standard of living for a resident is vastly different than that of a physician with a family 20 years down the road.

While insurance companies’ underwriting standards are typically structured in a way that prevents you from collecting the exact same amount of monthly income you were making pre-disability, your goal should be to get as close as possible.  In other words, if you are a dentist earning $20,000 a month and need to file a claim, you don’t want to have to end up relying on a disability policy with a monthly benefit of $5,000 as your primary source of income.

Often policies have future increase options that allow you to purchase additional coverage without changes to the terms of the existing policy.  Typically, these options will only be available during certain discrete time periods set forth in the policy, so it’s important to read your policy carefully to make sure you don’t miss out on the opportunity to take advantage of an increase option.

If your policy does not have increase options and you’ve outgrown the monthly benefit amount, you can also purchase another policy to increase the total coverage you would receive if you filed a claim.  However, if you’re going to be purchasing a new policy, you need to keep in mind that you must purchase a policy that compliments you’re existing coverage, and does not cancel out your other policy or policies.

For example, some policies contain provisions stating that a claimant cannot collect total disability benefits if he or she is working in another profession (a “no-work” provision).  Other policies require the policyholder to work in some other capacity, in order to collect total disability benefits (a “work” provision).  Thus, if you were to purchase a new policy with a “work” provision, and your old policy had a “no work” provision, one of the policies would be rendered useless (because it would be impossible to collect total disability benefits under both policies).

When purchasing a new policy, it’s also important to keep in mind that disability policies have become increasingly more complex, restrictive and less favorable to policyholders over time.  There is no longer a “standard” policy that every company sells—each policy will have it’s pros and cons, and it is therefore important to take your time to familiarize yourself with the policy at the point of sale, so that you know what you’re purchasing.  And if you didn’t pay close attention when you purchased the policy, or you can’t remember exactly what your policy says, you should review your policy to assess whether it still meets your needs and make sure that you have an accurate understanding of the scope of your coverage.


Are There Options Besides A Trial When My Claim is Denied?

Reducing the risk of having to fight for benefits requires understanding the terms of your policy from the beginning, carefully and thoroughly filling out the application, and ensuring accuracy and consistency in your claim packet and subsequent filings. As the saying goes, the best defense is a good offense, and the best way to avoid litigation is to file the claim correctly the first time.

Although filing a successful claim is not easy, it is the ideal.  Unfortunately, insurance companies have a strong incentive to increase their bottom lines and often they practice aggressive tactics in improper attempts to justify the denial or termination of even a wholly legitimate claim. If your claim has been terminated or denied, it can seem overwhelming or hopeless to try to reverse the decision.  In the event of a denial or termination, many insureds know they can sue their insurer and go to trial.  Yet, even if you are ultimately successful in a lawsuit, litigation can sometimes drag on for years.  While a lawsuit is pending, you’ll not only have legal expenses, but will also not be receiving benefits (and likely not be in a position to work to offset your expenses, due to the nature of your disability or your policy’s language). There are, however, some alternative options that can be attractive to both parties that policyholders may not be aware of, namely mediation and lump sum settlements.

Mediation

All too often we see legitimate claims denied or terminated, with the insurance company refusing to reconsider their position. If your claim is terminated, the company knows that it wields a lot of power over the denied individual, including the power of money, the power of time, the power of institutional knowledge, and the power to tolerate litigation.  In other words, insurers calculate that spending money on even protracted litigation will end up being cheaper than continuing to pay benefits, and they know that many claimants will just give up and go away if they draw out court proceedings long enough.

While this might sound bleak, there can be alternatives to a full-fledged lawsuit that culminates in a trial (and potentially drawn-out appeals).  One such method is mediation.  Mediation is where the parties to a lawsuit meet with a neutral third party in an effort to settle the case.

For the most part, mediators are retired judges, or active or retired attorneys. The mediator reviews the case file and then meets with both parties, seeking  to facilitate discussions between the parties and try to find common ground in order to reach  an acceptable compromise. Because mediation is not binding, the mediator’s recommendation and any subsequent agreement between the parties is not final until the parties memorialize it by putting all the agreed upon terms in writing and signing the document.

Often the insurance company will offer to draft the agreement so they can have control over what the agreement says, and so it is important to stay engaged in the process even after the mediation has ended, in order to ensure that the parties’ agreement is accurately documented.  The settlement agreement itself is a very important document, so you should be sure to take the time to carefully review it before signing, to be sure it encapsulates all the agreed upon terms.

It is also important to keep in mind that mediation typically does not result in a full restoration of benefits nor is not always successful.  The non-binding nature of mediation means that if the insurance company low-balls and refuses to budge in its offer, the claimant may need to just walk away and resume litigation.

Lump Sum Settlement

Another way of avoiding trial is through negotiating a lump sum settlement.  This typically occurs outside of the mediation setting, but sometimes requires the filing of a lawsuit before the insurance company is willing to come to the table.  When this happens, your insurer agrees to buy out your policy and you release your right to collect under your policy and your insurer from any obligation to you.  The buyout amount will be your policy’s “present value” (i.e. the amount of money you could invest upon receipt, based on a determined interest rate, and end up with the same amount of money you would have received in benefits at the end of your policy), discounted by a percentage that is negotiated by the parties.

A buyout can be an attractive offer and can occur at any stage of the litigation process.  A lump sum buyout could even be a preferable alternative to having benefits reinstated, as you would no longer have to deal with your insurer.  Your benefit payments would cease being on hold pending the outcome of a trial and you could invest the lump sum in order to provide for your and your family’s future. In addition, unlike monthly disability benefits, the lump sum settlement you receive would be inheritable and available to be passed on to your heirs, should something happen to you.

There are, however, certain drawbacks to a lump sum buyout, including the fact that you and your insurers cannot accurately predict the future of the market with 100% certainty, so the calculations will only be a best estimate.  If you are healthy and have lifetime benefits, you could also receive more money cumulatively over time if you were to stay on claim.  So, while attractive, especially when faced with litigation, the pros and cons must be carefully weighted when considering lump sum buyouts during the litigation process.

We often see claimants who face the loss of their benefits simply give up and accept a denial, daunted by the thought of protracted litigation.  While litigation may sometimes be the most advisable way to get benefits, and possibly punitive damages, there are other avenues to explore, advisably with the help of an attorney, that can end in your retaining at least some of the benefits you stand to lose completely when an insurance company denies your claim.

 

 

 

 


Can A New Blood Test Objectively Prove Fibromyalgia?

As we’ve discussed in more detail in a previous post, fibromyalgia is a syndrome characterized by chronic, wide-spread muscle pain as well as fatigue, difficulty sleeping, depression or anxiety, muscle knots, cramping, or weakness, painful trigger points, and headaches.  Fibromyalgia can be difficult to diagnose, given the relative or subjective nature of most symptoms.  Symptoms can also mimic those of rheumatoid arthritis and other diseases, so often a diagnosis is established after other causes of symptoms are ruled out.  Doctors will examine a patient’s history, conduct a physical examination, as well as evaluate X-rays and blood work.  Doctors will also test patients for 18 tender points.  The American College of Rheumatology guidelines suggest that those with fibromyalgia have pain in at least 11 of these tender points.[1]

Although the majority of fibromyalgia cases are diagnosed chiefly by ruling out other conditions, many patients may now have access to a blood test that may diagnose the disease.  In 2012 a privately held biomedical company, EpicGenetics, released the FM/a® Test, which is an FDA-compliant blood test designed to diagnosis fibromyalgia.  The test identifies the presence of certain white blood cell abnormalities.[2] The use and accessibility of the test has been growing,  as Medicare and an increasing number of private insurance providers have begun covering the costs,[3] and the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) has also recently agreed to cover the cost of testing.[4]

The blood test works by analyzing protein molecules in the blood called chemokines and cytokines.  Founder and CEO of EpicGenetics, Bruce Gillis, MD, explains that those with fibromyalgia have a lower count of these protein molecules in their blood, leading to weaker immune systems.[5]  A diagnosis of fibromyalgia the traditional way can take, on average, more than two years.[6]  Many believe that FM/a® offers an objective and concrete diagnosis that allows sufferers to more quickly find adequate resources and treatment.

However, others argue that the test does not offer the diagnosis it promises.  Some argue that fibromyalgia is not a discrete medical condition but rather a “symptom cluster” or that the biomarkers the test identifies are also found in people with different illnesses, such rheumatoid arthritis.[7] As of this writing, major medical resource databases such as MedLine Plus, the CDC, and the Mayo Clinic continue to state that there is no lab test or definitive way to diagnose fibromyalgia.

As we’ve previously discussed, disability insurance policy holders can often face challenges with they go to file a claim based on disabilities, such as fibromyalgia, that are considered “subjective conditions.”  A test promising objective proof may remove some of these challenges. However, it remains to be seen how insurance companies and the medical community as a whole will agree on what constitutes objective proof of fibromyalgia, whether via this test or other medical advances down the road.

 

[1] 18 Points Used to Diagnose Fibromyalgia, Health, http://www.health.com/health/gallery/0,,20345635,00.html#where-does-it-hurt–1
[2] Businesswire, EpicGenetics with the Assistance of Leading Medical Centers, Expands Clinical Study of FM/a® Test to Diagnose Fibromyalgia, Identify Genetic Markers Unique to the Disorder and Explore Direct Treatment Approaches, Yahoo! Finance, Apr. 19, 2017, https://finance.yahoo.com/news/epicgenetics-assistance-leading-medical-centers-120000519.html
[3] Pat Anson, Fibromyalgia Blood Test Gets Insurance, Pain News Network, May 27, 2015, https://www.painnewsnetwork.org/stories/2015/5/27/fibromyalgia-blood-test-gets-insurance-coverage
[4] Emily Riemer, Mass General researcher investigating possible fibromyalgia vaccine, WCVB5, July 27, 2017, 6:05 p.m., http://www.wcvb.com/article/mass-general-researcher-investigating-possible-fibromyalgia-vaccine/10364683
[5] Anson, id.
[6] Getting a Diagnosis, Fibrocenter, http://www.fibrocenter.com/pain
[7] Anson, id.


Myofascial Pain Syndrome

 

In previous posts, we have discussed the challenges attendant to chronic pain, including how dentists often experience pain due to the unnatural and static positions they must maintain for extended periods of time (which place stress on their musculoskeletal and muscular systems).  This post will delve further into one such chronic pain condition, myofascial pain syndrome (MPS).

Overview

Myofascial pain syndrome is a chronic pain condition that affects the fascia (the connective tissues that spreads throughout the body).  Specifically, myofascial pain syndrome refers to the pain and inflammation of muscles and soft tissue.

With someone suffering from myofascial pain syndrome, pressure on sensitive points in muscles (trigger points) can cause pain in seemingly unrelated parts of their body (called referred pain). A single muscle or a muscle group may be involved. Typically, the pain affects one side of the body only, or one side significantly more than the other.  There may also be tenderness in areas not experiencing chronic pain.

Symptoms

While many people experience muscle pain or tension, those who suffer from myofascial pain syndrome experience persistent and worsening pain.  Additional symptoms include:

  • Deep and aching pain at specific trigger or tender points
  • Spasms
  • Tenderness
  • A knot or clump in a muscle area
  • Insomnia or sleep disturbances
  • Fatigue
  • Depression (which often co-occurs with MPS)

Causes

The pain and strain in a muscle caused by a trigger point associated with MPS can be attributed to numerous sources, including:

  • Injury or prior injury
  • Excessive strain or overuse of a muscle or muscle group
  • Unnatural movements
  • Repetitive motions
  • Poor sleep schedules and sleeping positions
  • Fatigue
  • Certain medical conditions (e.g. heart attack)
  • Lack of activity
  • Stress or anxiety

Diagnosis

Because there are no visual indicators such as redness or swelling associated with MPS, doctors typically will perform a physical exam that includes applying pressure to the painful area.  A doctor will feel for trigger points, which are divided into four types:

  • Active – an area of extreme tenderness associated with local or regional pain.
  • Latent – a dormant area that has the potential to act like a trigger point, and may be associated with numbness or restriction of movement.
  • Secondary – a highly irritable spot in a muscle that may become active due to a trigger point, or if there is overload on another muscle.
  • Satellite Myofascial Point – a highly irritable spot that becomes inactive because the muscle is in the region of another trigger point.

Although not as common, physicians may use Electromyography (EMG) to locate trigger points.  In addition, doctors will usually conduct additional tests and procedures to rule out other causes of the muscle pain (e.g., lab tests to rule out vitamin deficiency).

Treatments:

Myofascial pain is treated using a variety of techniques, often in conjunction, such as:

  • Medication (e.g. pain medications, medication for muscle spasm, antidepressants)
  • Trigger point injections (which typically contain a local anesthetic or saline, sometimes with corticosteroid)
  • Physical Therapy
  • Spray and stretch (a treatment where a cooling agent is sprayed on the sore muscle, followed by gentle stretching)
  • Massage Therapy
  • Acupuncture
  • Heat Therapy
  • Ultrasound
  • Posture and Stretching Training

Exercise, relaxation, and a healthy diet are also recommended techniques to help alleviate MPS pain.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

 

References:

Mayo Clinic, http://www.mayoclinic.org/
WebMD, http://www.webmd.com/
Cleveland Clinic, clevelandclinic.org
MedicineNet, https://www.medicinenet.com/script/main/hp.asp
Chowdhury, Nayeema, OMS IV and Leonard Be. Goldstein, DDS, PhD, Diagnosis and Management Of Myofascial Pain Syndrome, Practical Pain Management, last updated March 19, 2012, https://www.practicalpainmanagement.com/pain/myofascial/diagnosis-management-myofascial-pain-syndrome.

 

 

 


Post-Traumatic Stress Disorder (PTSD)

In prior posts, we’ve examined how the demands of practicing render physicians and dentists uniquely susceptible to anxiety and depression.  In this post, we are going to examine Post-Traumatic Stress Disorder (PTSD), another serious condition that often affects doctors—particularly doctors who work in high stress environments and who are repeatedly exposed to trauma on a daily basis.

What is PTSD?

PTSD is a mental health disorder caused by exposure to a shocking or dangerous event.  Although most people who experience a traumatic event experience an immediate emotional response when they are experiencing the event, those who develop PTSD continue to experience the symptoms of exposure to trauma after the event, and feel stressed or panicked even when there is no danger.  While some of the symptoms are similar to other anxiety disorders, PTSD is categorized as a particular type of anxiety that is caused by a specific external catalyst.  The onset of PTSD can occur within months after a traumatic event; however, in some cases symptoms may not appear until years later.

Prevalence

PTSD is associated with those who have been exposed to a traumatic event, such as combat, violence, serious accidents, or natural disasters.   Approximately seven to eight percent of the U.S. population will have PTSD at some point in their lives, with about eight million adults suffering from PTSD in any given year.[1]

PTSD can be caused by one event, or by prolonged exposure to trauma over time.  This exposure can be experienced directly, and through indirect exposure (i.e. witnessing the event).[2]

Many physicians, depending on their specialty, interact on a daily basis with traumatic situations from early on in their careers, and sometimes encounter events where patients die or are seriously harmed in a way that is very distressing to a practitioner.  Significantly, research has shown that 13 percent of medical residents meet the diagnostic criteria for PTSD.[3]  Emergency physicians, physicians practicing in remote or under-served areas, and physicians in training (i.e. residents) are particularly prone to developing PTSD.[4]

The prevalence of PTSD is also substantially elevated in individuals who are also suffering from chronic pain.  While only 3.5 % of the general population has a current PTSD diagnosis, one study found that 35% of a sample of chronic pain patients had PTSD.  Another study of patients with chronic back pain showed that 51% experienced significant PTSD symptoms.  In instances where the chronic pain is caused by the traumatic event (e.g. someone involved in a motorcycle accident or someone injured during the course of a violent crime), the pain can serve as a reminder of the event and worsen the PTSD.[5]

Symptoms

Physicians who suffer from PTSD may lose this ability to confidently react, which can impair their ability to safely practice.  Untreated, PTSD can also lead to a marked decline in quality of life, and potentially other mental health disorders or medical issues.  Some common symptoms of PTSD include:

Re-experiencing symptoms:

  • Flashbacks
  • Nightmares
  • Frightening thoughts
  • Physical reactions or emotional distress after exposure to reminders
  • Intrusive thoughts

Avoidance symptoms:

  • Staying away from places, events, or objects that are reminders to the traumatic experience
  • Avoiding thoughts or feelings related to the traumatic event

Arousal and reactivity symptoms:

  • Being easily startled
  • Feeling tense and “on edge”
  • Having difficulty sleeping
  • Being irritable or aggressive
  • Heightened startle reaction

Cognition and mood symptoms:

  • Trouble remembering key events of the traumatic event
  • Negative thoughts about the world, and oneself
  • Distorted feelings of guilt or blame
  • Loss of interest in previously enjoyed activities
  • Negative affect

Diagnosis

PTSD is typically diagnosed by a clinical psychiatrist or psychologist.  A diagnosis is made when an individual meets the criteria for exposure, and has at least one re-experiencing symptom, one avoidance symptom, two arousal and reactivity symptoms, and two cognition and mood symptoms.

Treatments

Some of treatments that are used, either alone or in conjunction, to treat PTSD include;

  • Cognitive Behavioral Therapy
  • Eye Movement Desensitization and Reprocessing (EMDR)
  • Prolonged Exposure Therapy
  • Antidepressants
  • Anti-anxiety medication
  • Medication for insomnia

The intensity and duration of PTSD symptoms varies.  Individuals who recognize any of the above-referenced symptoms in themselves should talk to a treatment provider right away.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described above and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

 

References:

Medscape, http://emedicine.medscape.com

National Institute of Mental Health, https://www.nimh.nih.gov

WebMD, http://www/webmd.com/

[1] U.S. Department of Veterans Affairs, PTSD: National Center for PTSD, How Common Is PTSD?, https://www.ptsd.va.gov/public/ptsd-overview/basics/how-common-is-ptsd.asp

[2] U.S. Department of Veterans Affairs, PTSD: National Center for PTSD, PTSD and DSM-5, https://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp

[3] Myers, Michael, MD, PTSD in Physicians, Psych Congress Network, Sept. 16, 2015, https://www.psychcongress.com/blog/ptsd-physicians

[4] Lazarus, A., Traumatized by practice: PTSD in physicians, J Med. Pract. Manage., 2014 Sept-Oct; 30(2): 131-4.

[5] DeCarvalho, Lorie T., PhD, U.S. Department of Veterans Affairs, PTSD: National Center for PTSD, The Experience of Chronic Pain and PTSD: A Guide for Health Care Providers,  https://www.ptsd.va.gov/professional/co-occurring/chronic-pain-ptsd-providers.asp


How Long Does It Take to Get Benefits? – Part 2

In an ideal world, you’d receive a favorable decision and your first benefit check shortly after your policy’s elimination period is satisfied.  Unfortunately, even wholly legitimate claims get scrutinized, questioned, delayed, and in some cases, denied.  Below are a few common reasons benefit payments are delayed, particularly at the outset of a claim.

1. Improperly Completed/Partially Completed Forms

If your initial claim forms are missing information, unreadable, or incomplete, your insurer will likely issue additional forms for completion or use the missing information as an excuse to delay processing the claim.  This applies to both the forms that you are required to complete and sign and the forms the insurer gives you to give to your doctor to fill out, so it is important to follow up with your doctor and make sure that all of the necessary forms are completed and returned in a timely fashion.  If you do not carefully document your claim, and you do not promptly respond to requests for follow-up information, most insurers will delay making a claim decision until you provide them with the requested information.

2. Pending Requests for Information

At the outset of your claim, your insurer will require you to sign an authorization that allows them to request a wide range of information from a wide range of sources, including your doctors and employer.  Oftentimes, the insurer will request information from these other sources (without telling you) and then will delay making a decision on your claim if any of these requests remain pending.

This means that even if you provide the insurance company with everything they requested from you, there may be other information that the company is waiting that is holding up the claims decision.  Consequently, it’s important to ask the insurance company to find out if there are any pending requests, adn then follow up with your doctors, employers, etc. as needed to ensure that the information is provided.

It’s also important to keep tabs on the pending requests, to determine whether the scope of the insurer’s investigation is appropriate.  An experienced disability attorney can advise you on whether a particular request for information is warranted under the circumstances of your particular claim.

3. Failure to Schedule Medical Examinations/Interviews

When you file a disability claim, insurers will almost always require that you participate in a detailed interview and/or undergo an independent medical examination (IME).  While the stated point of these requests is to confirm or verify your disability, they can often be an attempt by your insurer to discredit your own doctor or medical records and generate fodder to deny your claim.  Depending on the nature of your condition, your insurer might also request other types of interviews or exams—such as a functional capacity evaluation (FCE) or neuropsychological evaluation.

Some claimants (mistakenly) believe that if they keep putting off these exams, then they’ll be able to avoid the exams.  However, most disability policies contain a provision that expressly requires the policyholder to submit to exams, and states that failure to do so is grounds for denying a claim or terminating benefits.  So if you put off these exams, it’s only going to delay the company’s claim decision, and possibly result in a claim denial.  However, keep in mind that going into a medical examination, IME, or interview unprepared can be just as bad for your claim, so it’s very important to prepare beforehand.  Once again, an experienced disability attorney can advise you regarding the proper scope of an interview or IME, and can also be present for the interview or IME, if desired.

 


How Long Does It Take to Get Benefits? – Part 1

You’ve made the difficult decision to give up practicing and file a claim.  You’re not working and you need to collect the disability benefits you’ve likely paid years of high premiums for.  So how long will you have to wait until your first benefit check arrives?

Unfortunately, the answer is not clear cut—it depends on the terms of your policy, your insurance company, the assigned benefits analyst, and the complexity of your claim, among other things.

Filing a Claim

Your policy should outline the requirements for filing a claim.  Typically, you must give notice of your claim to your insurer within a certain time frame.  If you miss this important deadline, the insurance company will typically claim that you have prejudiced its ability to investigate your claim, and use this as an excuse to delay making a decision on your claim.  Significantly, if you don’t provide timely notice, it can also foreclose your ability to collect benefits (depending on the circumstances, and the reason for the delay).

Once you file your claim with your insurer, they will then send claim forms to be completed by you and your physician.  Your policy should include a deadline for when your insurer must provide you with these forms (e.g. 15 days).  If they don’t provide you with forms within this time frame, most policies allow you to submit a written statement documenting your proof of loss, in lieu of the forms.   Again, there is a deadline to return these forms and failing to do so gives your insurer an excuse to prolong the decision-making process.

Elimination and Accumulation Periods

Your policy will also contain details about your elimination period.  This is the period of time that must pass between your disability date and eligibility for payment on a claim.  Generally, you must be disabled (as defined in your policy) and not working in your occupation during this time period.

Depending on the terms of your policy, this period does not necessarily have to be consecutive, but it does need to occur within the accumulation period also set out in your policy (for example, your policy might require a 90 day elimination period that must be met within a 7 month accumulation period).  You will not be eligible for payment until the elimination period has been fulfilled.  Typically, insurers won’t provide you with a claim decision until after this date has passed.

It is important to be aware of your elimination period, so that you can plan accordingly (and are not expecting a benefit payment to arrive right way when you are budgeting to meet living expenses, or debts like student loans).   Also, it’s important to keep in mind that receiving a benefit payment immediately following the elimination period is the ideal scenario.  In many claims, it takes much longer for a benefit to be issued.  In our next post, we will address some of the most common reasons benefit payments are delayed.


Policy Riders: Social Insurance Substitute Rider

In prior posts we’ve talked about riders and how they can modify the terms of a disability policy.  In this post, we will be looking at a rider we sometimes see in individual disability policies called a Social Insurance Substitute (SIS) rider.

An SIS rider is an optional rider that provides a monthly benefit that works a little differently than a standard base benefit.  Generally speaking, SIS benefits can be reduced if you are eligible for and receiving social insurance benefits (e.g. Social Security retirement or disability benefits, workers’ compensation benefits, etc.).

SIS riders can operate differently, depending on the terms of your policy.  In some instances, the benefit paid by the insurer will be reduced by the amount received from social insurance (usually up to a certain amount).  In other policies, a certain percentage is subtracted from the benefits based on how many different forms of social insurance you are receiving (e.g. if you are receiving Social Security benefits, you might only receive two-thirds of your monthly benefit amount, and your monthly benefits might be further reduced if you started receiving benefits from a second source, like worker’s compensation).

The appeal of the SIS rider is that including it in a policy will typically result in a lower premium.  The logic behind this is that the insurance company shares the risk of payment with the government.  The primary downside to an SIS rider is the fact that your benefits will be reduced in some fashion if you obtain social insurance benefits.

In addition, policies with an SIS rider can also place additional requirements on policyholders by:

  1. Requiring policyholders to apply for social insurance benefits;
  1. Requiring policy holders to reimburse them if a lump sum payment is received from social insurance(s); and
  1. Requiring policyholders to go through the entire appeals process following any social insurance denials and/or re-apply for social insurance benefits periodically.

When choosing a policy, it is important to weigh what you can afford in premiums now with potential future benefits.  If you can afford a higher premium, it is often in your best interest to choose a policy without an SIS rider and with a higher base benefit.  As we have discussed previously, there are also certain riders that you can purchase that will automatically increase your monthly benefit (and premiums) by a certain amount each year and/or allow you to apply to increase your monthly benefit in the future, without undergoing additional medical underwriting.  Whether you are shopping for a policy, or evaluating your existing policy, you should always keep in mind that the cost of the premium is not the only consideration.  There are other factors in play that you must consider when purchasing a policy, and the type of insurance that you purchase can have a significant impact upon your financial position if you should become disabled.


Migraine Headaches

Migraine headaches can be debilitating, and, in some cases, chronic.  In this post, we will look at some of the symptoms of migraines, how they are diagnosed, and some common treatments for migraines.

Overview

Migraines are characterized by severe headaches that usually involve throbbing pain felt on one side of the head, and can be accompanied by symptoms such as nausea, vomiting, and/or sensitivity to light and sound.

Migraines are the third most prevalent illness in the world, and can interfere with an individual’s ability to work and complete day-to-day activities, especially for those suffering from chronic migraines.  Some studies have determined that healthcare and lost productivity costs associated with migraines may be as high as $36 billion annually.  Migraines can affect anyone—in the U.S. 18% of migraine sufferers are women, 6% are men, and 10% are children.  They are more common in individuals aged 25 to 55 and in those with family members that also suffer from migraines.[1]

Symptoms

Migraine symptoms, frequency, and length vary from person to person.  However, they usually have four stages:

Prodrome: This occurs one or two days before a migraine attack and can include mood changes, food cravings, neck stiffness, frequent yawning, increased thirst and urination, and constipation.

Aura: This stage can occur before or during a migraine attack.  Auras are usually  visual disturbances (flashes of light, wavy or zigzag vision, seeing spots or other shapes, or vision loss.  There can also be sensory (pins and needles, numbness or weakness on one side of the body, hearing noises), motor (jerking), or speech (difficulty speaking) disturbances.  While auras often occur 10 to 15 minutes before a headache, they can occur anywhere from a day to a few minutes before a migraine attack.  Typically, an aura goes away after the migraine attack, but in some cases, it lasts for a week or more afterwards (this is called persistent aura without infarction).

Migraine: The migraine itself consists of some or all of the following symptoms:

    • Pain on one or both sides of the head that often begins as a dull pain but becomes throbbing
    • Sensitivity to light, sound, odors, or sensations
    • Nausea and vomiting
    • Blurred vision
    • Dizziness and/or fainting
    • Migrainous stroke or migrainous infraction (in rare cases)

Post-drome: This stage follows a migraine and can include confusion, mental dullness, dizziness,  neck pain, and the need for more sleep.

A migraine can last anywhere from a few hours to several days, and there are several classifications of migraines, including:

  • Classic migraine – migraine with aura
  • Common migraine – migraine without aura
  • Chronic migraine – a headache occurring at least 15 days per month, for at least three months, eight of which have features of a migraine
  • Status migraine – (status migrainosus) a severe migraine attack that lasts for longer than 3 days

Causes

The exact causes of migraines are not clearly understood but involve abnormal brain activity, including (1) changes in the brain stem and its interactions with the trigeminal nerve and (2) imbalances in brain chemicals, including serotonin.  Migraines are most often triggered by:

  • Food and food additives (often salty or aged food, MSG, meats with nitrites, aspartame)
  • Skipping meals
  • Drink (alcohol, caffeine, caffeine withdrawal)
  • Sensory stimuli (bright or flashing lights, strong odors, loud noises)
  • Hormonal changes or hormone medication such as birth control
  • Certain other medications
  • Stress or anxiety
  • Strenuous exercise or other physical stress
  • Change in sleep patterns
  • Changes in weather

Co-occurrence

Migraines have been shown to co-occur with several other conditions[2], including:

Treatment

There are a variety of options that doctors employ to both treat and prevent migraine attacks.

  • Pain-relieving medications (both over the counter and prescription)
  • Preventative medications (which can include antidepressants, blood pressure medications, and seizure medications)
  • Botox
  • Transcutaneous supraorbital nerve stimulation (t-SNS) (a headband-like device with attached electrodes)
  • Acupuncture
  • Biofeedback
  • Massage therapy
  • Cognitive behavioral therapy (CBT)
  • Herbs, vitamins, and minerals
  • Relaxation exercises
  • Sticking to a sleep schedule
  • Exercise
  • Avoidance of known triggers

Doctors also sometimes recommend keeping a headache diary, similar to a pain journal, which can help you track the frequency of your migraines and may help identify triggers.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional.  If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose.  Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

References:

Cedars-Sinai, https://www.cedars-sinai.edu
Healthline, www.healthline.com
Mayo Clinic, www.mayoclinic.org
MedlinePlus, www.medlineplus.gov

 

[1] Migraine Research Foundation, About Migraine, http://migraineresearchfoundation.org/about-migraine/migraine-facts/

[2] Wang, Shuu-Jiun, et. al., Comorbidities of Migraine, Frontiers in Neurology, Aug. 23, 2010, http://journal.frontiersin.org/article/10.3389/fneur.2010.00016/full

[3] Id. (citing Von Korff M., et. al., Chronic spinal pain and physical-mental comorbidity in the United States: results from the national comorbidity survey replication, Pain 113, 331-330 (2005).


“Transitional Own Occupation” Provisions

In prior posts, we’ve talked before about how an individual disability policy with a true “own occupation” provision is ideal.   Under this type of provision, you are “totally disabled” if you are no longer able to perform the material and substantial duties of your occupation (for example, you can no longer perform dentistry), and you can still work in a different field and receive your full benefits (if you are able and choose to do so).

Most doctors looking for a disability policy know that it’s important to get an “own occupation” policy, but may not realize that there are several, less-favorable provisions that are also styled as “own occupation” provisions.  These provisions contain the phrase “own occupation,” but also contain language that can dramatically impact a doctor’s ability to collect.  For example, a policy might provide benefits if you are no longer able to work in your occupation, but only if you are not working in any other occupation.   And some newer disability policies actually require you to work in another occupation in order to collect benefits.

Another type of restriction we’ve been seeing recently is a “transitional own occupation” or “transitional your occupation” policy.  As we stated above, under the true “own-occupation” policies prevalent in the 80’s and 90’s, you can work in another profession and still collect full benefits, regardless of whether you make less, the same, or more than when you were practicing.  With “transitional own occupation policies”  or “transitional your occupation policies,” you can work in another profession, but your benefits are reduced if your total income (from your benefits, employment, and other insurance benefits) ever exceeds what you made immediately prior to your disability.  So, with these types of policies, your earning potential is essentially capped at what you were making before you became disabled (if you want to keep receiving benefits under your policy).

Transitional own occupation policies may seem attractive because they may have lower premiums, but it is important to know that they are not the same as true “own occupation” policies, and they can result in a reduced benefit payment and/or limit your options if an lucrative employment opportunity should ever arise.

While many policies contain the phrase “own-occupation,” including “transitional own occupation” provisions, they often aren’t true own-occupation policies and you shouldn’t rely on an insurance agent to disclose this information.  Oftentimes, your agent may not even realize all of the ramifications of the language and definitions in the policy that he/she is selling to you. Additionally, most of the newer disability policies now contain language saying that you cannot rely on an agent’s statements and/or that agents cannot change the terms of a policy.  Consequently, you should always read a policy from start to finish and make sure you have a clear understanding of what you are buying, before purchasing a disability policy.