Do I Have to Keep Paying Premiums Even Though I’m Disabled?
If you are thinking about filing a disability claim, you are likely wondering whether you will be able to meet your monthly expenses if you’re no longer able to work. You may have made a list of your necessary expenses, and likely included your disability insurance premium payments on that list, as your agent likely told you that your policy would lapse and you would lose your coverage if you missed a premium payment. At this point, you probably started to wonder whether you still have to keep paying the premium after you file the disability claim, and if so, for how long?
The answer depends on the specific terms of your policy. The paragraph that you’ll want to look for when you’re reviewing your policy is typically titled “waiver of premium,” but some policies address waiver of premiums as part of a larger section of the policy that discusses premiums more generally.
How Do Waiver of Premium Provisions Work?
Generally speaking, waiver of premium provisions state that your disability insurance company cannot charge premiums during periods of time when you are disabled. A waiver of premium provision typically will also require your insurance company to reimburse you for premiums you have previously paid during your period of disability (i.e. the premiums that you paid while the insurance company was investigating your claim).
Waiver of premium provisions are included in most disability insurance policies. If you are considering purchasing a policy that does not include a waiver of premium provision, you may have the option to purchase a waiver of premium rider.
Here is an example of a waiver of premium provision from an actual disability insurance policy.
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Waiver of Premium Benefit
We will waive Premiums of this Policy from the date of Total Disability after the later of:
- 90 consecutive days of Total Disability, or
- The end of the Elimination Period.
When we approve the Waiver of Premium, We will refund any Premiums paid from the first day of Total Disability. Waiver of Premium will continue while You are receiving a Total or Partial Disability Benefit of this Policy or a Rider. When You are no longer eligible for Waiver of Premiums, You must resume payment of Premiums to keep Your Policy in force.
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Under this policy, the waiver of premium provision requires you to pay premiums either for 90 consecutive days after you become disabled, or until the end of the elimination period (the elimination period is the number of days you must be disabled before you are entitled to benefits, and is usually noted on the first few pages of a policy).
So, for example, under this policy, once you have been disabled for 90 consecutive days, you no longer would have to pay premiums (at least until you recover from your disability, or your insurer terminates your benefits). You also would receive a refund of any premiums that you paid for any period prior to your date of disability.
Notably, the waiver of premium provision above also requires you to be receiving benefits for the waiver to apply. This is significant because, depending on the terms of your policy, in some cases you could be disabled but not receiving benefits. For instance, your policy might have a foreign residency limitation that prevents you from receiving benefits if you are living in another country, even if you remain disabled. In such a case, you might have to resume paying premiums until you returned to the United States in order to keep your coverage in force.
The Takeaway
Timely and proper payment of premiums is critical, as a failure to pay premiums can result in you losing your disability coverage completely. It is important to read your disability insurance policy carefully so that you have a clear understanding of when you are required to pay premiums, and when you are entitled to a refund of past premiums.
Most insurance companies will provide you with written confirmation that premiums have been waived, and it is best to keep paying your premiums until you receive this written confirmation, even if you think that you no longer have an obligation to pay premiums under the terms of your policy. If you have questions about whether your insurance company should have waived and/or refunded premiums under the terms of your policy, an experienced disability insurance lawyer can review your policy and explain your rights and obligations under your particular policy.
I used to practice __________ but now I’m _____________?
As a dentist or physician, you spent years in school and invested countless hours to establish and maintain your practice. You even protected this investment by purchasing a disability policy. Yet, if you do become disabled and make a claim, your insurer might still make the argument that you are only trying to retire and get paid for it. Unfortunately, disability insurance claims by doctors and other healthcare professionals are especially targeted for denial or termination.
When you are disabled and are no longer able to practice in your profession, it may seem logical to simply refer to yourself as “retired,” especially if you are not working in another capacity. While it’s certainly understandable that you may not want to explain to everyone who asks why you’ve hung up your lab coat, you need to keep in mind that innocently referring to yourself as retired will likely prompt your insurer to subject your claim to higher scrutiny. Insurance companies often attempt to take statements out of context in order to deny or terminate disability benefits by alleging that a legitimately disabled claimant is:
- Malingering
- Making a lifestyle choice.
- Unmotivated by or unsatisfied with work.
- Embracing the sick role.
Remember, in the insurance company’s mind, there is a big difference between “disabled” and “retired.” Below are some common situations where you should avoid referring to yourself as retired:
- When asked for your profession on disability claim forms.
- When talking to your doctors or filling out medical paperwork.
- On your taxes, other financial forms, and applications.
- Around the office.
- At social functions or gatherings.
- On social media.
Disability insurers can—and often do—employ private investigators to follow claimants on social media; interview staff, family, or acquaintances; and track down “paper trail” documents (such as professional license renewal forms, loan applications, etc.) to see if you have made any statements that could be construed as inconsistent with your disability claim. Disability insurers also routinely request medical records and may even contact your doctor(s) directly regarding your disability. So, for example, saying something off-hand or even jokingly, such as “I’m retired—I can stay out as late as I want now!” to your doctor, or at a social event like a block party, could lead to your insurer trying to deny your claim if they later spoke to your doctor or your neighbor.
While the focus of your disability claim should be on your condition and how it prevents you from working, insurance companies can latch on to innocent statements like this in an effort to deny legitimate claims. Eschewing the word “retirement” is a good and easy first step to help avoid unwanted and unwarranted scrutiny from disability insurers.
Understanding Your Policy: Examination Provisions
Disability insurance companies are constantly searching for new ways to expand the power and control they have over their policyholders through the use of restrictive policy provisions. In previous posts we’ve discussed how disability insurers are expanding their control over their policyholders’ medical treatment by implementing more stringent care provisions. However, care provisions are not the only avenue for disability insurers to exert a greater degree of influence in the claims process. Over the years, disability insurers have also expanded the scope of their authority under examination provisions.
The most basic examination provisions simply notify the policyholder that he or she may be examined by the insurer’s doctor or interviewed by a representative of the insurer, like this policy from Northwestern Mutual:
- Medical Examination. The Company may have the Insured examined by a health care practitioner.
- Personal Interview. The Company may conduct a personal interview of the Insured.
- Financial Examination. The Company may have the financial records of the Insured or the Owner examined.
Taken alone, this does not seem to onerous. However, you need to watch out for additional requirements buried at the end of the provision:
Any examination or interview will be performed:
- At the Company’s expense;
- By a health care practitioner, interviewer or financial examiner of the Company’s choice; and
- As often as is reasonably necessary in connection with a claim.
The final sentence of this provision leaves the open the possibility of multiple interviews throughout the claim, and may be overlooked by a claimant who does not carefully review his or her disability insurance policy.
Other provisions, like this medical examination provision from a Standard Insurance Company individual disability insurance policy, expressly condition the payment of disability benefits on your cooperation with the exam:
MEDICAL EXAM – We can have Physicians or vocational specialists examine You, at Our expense, as often as reasonably necessary while You claim to be Disabled. Any such examination will be conducted by one or more Physicians or vocational specialists We choose. We may defer or suspend payment of benefits if you fail to attend an examination or fail to cooperate with the person conducting the examination. Benefits may be resumed, provided that the required examination occurs within a reasonable time and benefits are otherwise payable.
In newer policies the language used by the disability insurance companies has become ever more burdensome. For instance, some modern provisions for examinations and interviews create far more specific duties for the policyholder and condition the payment of disability benefits on the claimant’s satisfaction of these duties. Take this Guardian policy, for example, which outlines the policyholder’s duties and obligations to comply with examinations and interviews in very specific language:
We have the right to have You examined at Our expense and as often as We may reasonably require to determine Your eligibility for benefits under the Policy as part of Proof of Loss. We reserve the right to select the examiner. The examiner will be a specialist appropriate to the assessment of Your claim.
The examinations may include but are not limited to medical examinations, functional capacity examinations, psychiatric examinations, vocational evaluations, rehabilitation evaluations, and occupational analyses. Such examinations may include any related tests that are reasonably necessary to the performance of the examination. We will pay for the examination. We may deny or suspend benefits under the Policy if You fail to attend an examination or fail to cooperate with the examiner.
You must meet with Our representative for a personal interview or review of records at such time and place, and as frequently as We reasonably require. Upon Our request, You must provide appropriate documentation.
Examination provisions containing language this specific and this restrictive significantly limit your rights. The most significant change in the evolution of the examination provision is the number of obligations upon which your benefits are conditioned. This policy language allows disability insurers to use your benefits as leverage to compel your compliance with medical exams, interviews, and a litany of other examinations.
Review your disability insurance policy, and particularly your examination provisions in the “Claims” section, to determine what your rights, duties, and obligations are under your policy. Unfortunately, if your disability insurance policy requires to participate in examinations, a refusal will likely lead to a denial of benefits. However, you do not have to attend alone. No matter how restrictive the language in your disability insurance policy, you always have the right to have an attorney present for any examination or interview. If you have any questions about your duties or obligations under your disability insurance policy, contact an experienced disability insurance attorney.
Understanding Your Policy: Maximum Benefit Period
Your maximum benefit period is one of the most important provisions in your disability insurance policy. Its terms control the period of time during which you are eligible to receive disability benefits under your policy.
Oftentimes the maximum benefit period is more complicated than you may expect. For instance, most newer disability policies contain a benefit schedule that details the length of your benefit period more precisely, based upon your age at the time the claim is filed. This policy from MetLife contains a maximum benefit period schedule similar to those found in many disability insurance policies:
Table A. Maximum Benefit Period Varies By Age When Disability Begins
Age When Disability Begins Maximum Benefit Period
Before Age 61 To Age 65
At Age 61, before Age 62 48 Months
At Age 62, before Age 63 42 Months
At Age 63, before Age 64 36 Months
At Age 64, before Age 65 30 Months
At Age 65, before Age 75 24 Months
At or after Age 75 12 Months
As you can see, under this sort of provision, the maximum benefit period is reduced based upon how old you are when your disability begins.
It is important be aware that all of the relevant information for determining your maximum benefits period is not always located in the same part of your disability insurance policy. For example, your policy summary may contain an asterisk and then, in fine print at the bottom of the schedule state something like “*The Maximum Benefit Period may change due to your age at total disability. Please see Policy Schedule II.” Then, if you notice the fine print and turn to Schedule II, you see something similar to the MetLife schedule, above, that limits the benefit period based upon your age at the onset of disability.
Other disability insurance policies require a bit more calculation. For example, policies like this one from Mutual of Omaha take your Social Security Normal Retirement Age into account:
61 or less: to Age 65 or to Your Social Security Normal Retirement Age, or 3 years and 6 months, whichever is longer
62: to Your Social Security Normal Retirement Age or 3 years and six months, whichever is longer
63: to Your Social Security Normal Retirement Age or 3 years, whichever is longer
64: to Your Social Security Normal Retirement Age or 2 years and 6 months, whichever is longer
65: 2 years
66: 1 year and 9 months
67: 1 year and 6 months
68: 1 year and 3 months
69 or older: 1 year
If your policy contains a provision like this, you can use this calculator to determine your Normal Retirement Age, to determine exactly how long you are entitled to disability benefits.
Finally, it is important to note that many disability insurance policies have specific, limited benefit periods for certain conditions such as mental illness and substance abuse (and typically restrict coverage for these sorts of conditions to a short time frame—usually 1 or 2 years).
As you can see, the maximum benefit provision can take many different forms in a disability insurance policy. It is critical that you read your policy carefully and have a firm grasp on how your maximum benefit period provision affects your eligibility for disability benefits. If you have any questions about your disability insurance policy, contact an experienced disability insurance attorney.
The Devil Is In the Details: Long Term Disability Policies and Benefit Offsets
In a previous post, we discussed a feature of long-term disability insurance policies that is easily overlooked and frequently leaves policyholders feeling cheated and deceived by their insurer: the benefit offset provision. When a person signs up for a disability insurance policy, he or she expects to pay a certain premium in exchange for the assurance that the insurance company will provide the agreed-upon monthly benefit listed in the policy, should they ever become disabled. What many people do not realize is that some disability insurance policies contain language that permits the insurer to reduce the amount of monthly disability benefits it is required to pay if the policyholder receives other benefits from another source.
Worker’s compensation, supplementary disability insurance policies, state disability benefits, and social security are some of the most common “other sources” from which policyholders may unexpectedly find their disability insurance benefits subject to an offset. The frequency of offset provisions varies by policy type. They are more likely to appear in group policies and employer-sponsored ERISA policies, and are rarely found in individual disability insurance policies.
Benefit offset provisions can have significant and often unforeseen financial repercussions, as illustrated by the recent account of a couple from Fremont, Nebraska. As reported by WOWT Channel 6 News, Mike Rydel and his wife Carla were receiving monthly benefits under Mr. Rydel’s disability insurance policy with Cigna. Mr. Rydel had suffered a stroke in the fall of 2015 that had left him incapacitated and unable to work. The Rydels’ financial situation was made even more dire by Mr. Rydel’s need for 24-hour care, which prevented Mrs. Rydel from working as well.
In an effort to supplement his family’s income, Mr. Rydel applied for Social Security disability benefits. When his claim was approved, the Rydels expected a much needed boost to their monthly income. Unfortunately, due to an offset provision in Mr. Rydel’s policy, his monthly disability benefits under the Cigna policy were reduced as a result of the approved Social Security claim, and his family did not realize any increase in income.
The Rydels were understandably shocked when they were informed by Cigna that Mr. Rydel’s monthly disability insurance benefits would be reduced by the amount he was now receiving from Social Security, and that Cigna would be pocketing the difference. Perversely, the only party that benefited from Mr. Rydel’s SSDI benefits was Cigna, which was off the hook for a portion of Mr. Rydel’s monthly benefits. In response to an inquiry from WOWT, Cigna simply asserted that “coordination” of private insurance benefits and government benefits was a long-standing practice – an assurance that likely provided no solace to the Rydels.
The Rydels’ story highlights the importance of carefully reviewing every aspect of your disability insurance policy before signing. Benefit offsets, policy riders, occupational definitions, and appropriate care standards in your policy can significantly impact your ability to collect full benefits if you become disabled. You should review your disability insurance policy carefully to determine if it contains any offset provisions that may affect your benefits. If it does, you will need to take them into account when estimating your monthly benefits.
References:
http://www.wowt.com/content/news/Stroke-Victim-Suffers-Disability-Insurance-Set-Back-385758411.html
What is a Pain Journal and Why Are They Important?
In previous posts, we have discussed the importance of properly documenting your disability. In this post we are going to discuss one way you can document your disability—pain journals.
A pain journal is exactly what is sounds like—a journal in which you document your pain levels and symptoms each day. Creating this sort of record will not only provide you with documentation when filing your disability claim, but will also allow you to effectively communicate with your treatment providers regarding your symptoms, so that they can provide you with appropriate care. Oftentimes, depending on your disability, you will go several days or weeks without speaking to your treatment providers. A pain journal can help you easily recall and communicate to your treatment provider everything that has happened since you last met with them.
Tips for Creating a Pain Journal
When creating a pain journal, you want to be as specific as possible so that your record is complete. You also want to make sure that you describe your plain clearly, so that you will be able to understand what you meant when you refer back to your journal.
Here are a few things you might consider documenting in your journal:
- The location of the pain.
- The level of the pain (if you use a numeric scale, be sure to also describe the scale).
- The duration of the pain.
- Any triggers to the pain.
- Any medications you are taking.
- Whether the medications you are taking are effective or have any adverse side effects.
- Any other symptoms in addition to the pain.
When filling out your pain journal, you may have a hard time coming up with a description that fits the type of pain you are experiencing, since all pain is not the same. However, you should avoid the temptation to document your pain in a generic way. The type of pain you are experiencing is just as important as your pain levels, and it is something that your disability insurer will likely ask you to describe.
To that end, here is a list of adjectives that are commonly used to describe pain:
Cutting; Burning; Cramps; Knots; Deep; Pulsing; Sharp; Shooting; Tender; Tight; Surface; Throbbing; Acute; Agonizing; Chronic; Dull; Gnawing; Inflamed; Raw; Severe; Stabbing; Stiff; Stinging
Sample Pain Journals:
American Pain Foundation Form:
American Cancer Society Form:
Peace Health Medical Group Form:
The Four Functions of Insurance
In this post, we are going to discuss the four functions of an insurance company.
Introduction – The Promise
Insurance is not like any other business. Rather than selling a tangible product that you receive immediately upon paying for it, insurance companies are selling an important promise—a promise of protection, security and peace of mind if something goes wrong.
When you buy a car, you give someone money and you take a car home. When you buy groceries, you pay money and get your groceries. Insurance is different. With insurance, you give them money and trust, and hope and pray that you never have to collect.
The Four Functions of Insurance
The activities of an insurance company can be divided into four major functions:
1. Actuarial
The actuarial department is concerned with what kind of promise the company is going to sell and how much the promise should cost. Essentially, the actuaries’ role is to analyze the financial consequences of risk and price the company’s product in a way that will allow the company to make a profit. For example, an actuary working for a car insurance company might calculate the risk that potential customers will be in a car accident, and then adjust premium amounts to account for that risk so that the insurer can pay accident claims and still make money.
2. Marketing
The marketing department is concerned with how to get people to buy the promise being sold. They design ads and employ sales people. Basically, this department’s goal is to get people interested in buying the promise.
3. Underwriting
The underwriting department determines who the company should sell the promise to. Underwriters review applications and assess whether the company should allow applicants to purchase the promise. For example, the underwriting department of a life insurance company might review health questionnaires submitted by applicants to assess whether the level of risk is low enough to provide life insurance to the applicant.
4. Claims
The claims department’s role is to process and pay legitimate claims. While the first three departments are very much concerned about profitability, the claims department is not supposed to consider company profitability when adjusting a claim. If the actuaries made a mistake and sold a product that is costing the company too much money, the product was not marketed correctly, or if underwriting was too lax, the company is supposed to pay legitimate claims and bear the loss.
Conclusion
As we have discussed in previous posts, an insurance company has a legal obligation to treat its customers fairly and deal with its customers in good faith. Ideally, the disability insurance claim process should be simple. You should inform the company that you meet the standards of the contract, provide certification from a doctor of that fact, and collect your disability benefits. It is not supposed to be an adversarial process.
Unfortunately, in instances where one or all of the first three departments mess up, some insurance companies improperly shift the burden of making a profit onto the claims department. This, in turn, transforms the claims process into an adversarial process.
If you have an experienced disability attorney involved from the outset of your disability claim, your attorney can monitor the insurance company to make sure that they are complying with their legal obligations. If you have already filed a disability claim, but believe that your insurer is not properly processing your claim, an experienced attorney can review the insurer’s conduct and determine whether the disability insurer is acting in bad faith.
Deciphering Mental Disorders and Substance Abuse Policy Exclusions – Part 2
In Part 1, we looked at how disability insurance companies broadly define mental disorders and substance abuse. In this post, we will be looking at a sample mental disorder and substance abuse limitation provision.
What Does a Mental Disorder and Substance Abuse Limitation Look Like?
Here is a sample limitation provision from an actual disability policy (this provision is taken from the same policy containing the definition of “mental disorders and/or substance abuse disorders” discussed in Part 1):
maximum indemnity period means the maximum length of time for which benefits are to be paid during any period of total disability (see the Policy Schedule on Page 1). Benefits will not be paid beyond the policy anniversary that falls on or most nearly after your sixty-seventh birthday, or for 24 months, if longer, except as provided by this policy. In addition to any limitations described above, the maximum indemnity period for a disability due to a mental disorder and/or substance abuse disorder is also subject to the following limitations: (a) The lifetime maximum indemnity period is 24 months; (b) the 24-month limitation also applies to all supplementary benefits payable by virtue of your disability due to a mental disorder and/or substance abuse disorder; (c) any month in which benefits are paid for a mental disorder and/or substance abuse disorder (regardless of whether paid under the base policy any supplementary benefits or both) shall count toward the 24-month limitation; (d) this limitation applies to this policy and all supplementary benefits under this policy.
Note that this provision is not entitled “mental disorder limitation” or “substance abuse limitation.” Instead, it is entitled “maximum indemnity period.” In fact, this provision is actually part of the policy’s definition section, and not the main part of the policy—highlighting the importance of carefully reviewing the definitions in your disability insurance policy.
Note also that this particular provision provides that any month in which disability benefits are paid counts against the 24 month limit. So, for example, if you received disability benefits for a period of 12 months in connection with a substance abuse related disability, and subsequently returned to work, the next time you needed to file a claim related to a mental disorder or substance abuse, you could only receive a maximum of 12 months of disability benefits.
Conclusion
When purchasing a disability policy, watch out for mental disorder and substance abuse exclusions and limitations. Always be sure to ready your policy carefully so that you understand the scope of the protection you are purchasing. If you already have a disability policy, an experienced disability insurance attorney can review your policy and determine whether it contains any mental disorder or substance abuse limitations that might limit your ability to collect disability benefits under your policy.
Deciphering Mental Disorders and Substance Abuse Exclusions – Part 1
In previous posts, we have discussed how many disability policies contain mental disorder and/or substance abuse exclusions that either prevent claimants from collecting disability benefits under their policies, or severely limit claimants’ right to collect—usually to 24 months or less.
Sometimes, it can be hard to tell if your disability insurance policy contains such an exclusion. Policy language can be difficult to decipher, and it becomes even more difficult in cases where the terms of the exclusion are contained within multiple provisions of the disability policy.
In the next few posts, we are going to discuss mental disorder and substance abuse exclusions. In Part 1, we will look at an example of how insurance companies define mental disorders and substance abuse. In Part 2, we will look at an example of a mental disorder and substance abuse limitation provision.
How Do Insurance Company’s Define Mental Disorders and Substance Abuse?
Each policy’s definition varies, depending on the insurance company. Here is a sample definition taken from an actual insurance policy:
mental disorders and/or substance abuse disorders mean any of the disorders classified in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association (APA). Such disorders include, but are not limited to, psychotic, emotional, or behavioral disorders, or disorders relatable to stress or to substance abuse or dependency. If the Manual is discontinued, we will use the replacement chosen by the APA, or by an organization which succeeds it.
As you can see, this definition is quite broad and could potentially encompass quite a few disabling conditions. Since the policy provision does not actually list out specific disorders, at best you would need to consult the APA manual, in addition to your disability policy, to find out what this provision actually means. And if your particular disorder does not fit neatly within the APA’s framework, you will likely have to go to court to determine whether your disorder falls within the policy’s definition of mental disorders and/or substance abuse disorders.
Also, because the definition is based upon the “most current edition” of the Diagnostic and Statistical Manual of Mental Disorders published by the APA, the types of disorders covered by the limitation will change each time the APA publishes a new manual.
These are just a few of the reasons why disability claims involving mental disorders and substance abuse disorders can be particularly tricky. In the next post, we will look at an example of what a mental disorder/substance abuse disorder limitation provision looks like.
Case Study: The Importance of Proper Documentation
In previous posts, we have discussed the importance of properly documenting your disability claim. From the moment you file your disability claim, most insurers begin collecting as much documentation as possible in the hopes that they can use the documentation to deny your initial claim, or terminate your disability benefits later on.
Oftentimes, disability benefits are terminated without warning. For example, an insurance company may conduct covert surveillance over an extended period of time, and then suddenly terminate your disability benefits once they feel that they have sufficient footage to assert that you are not disabled. If you are not consistently documenting the ongoing nature and extent of your disability, you may find yourself lacking sufficient evidence to contest a denial or termination of benefits.
For example, in the recent case Shaw v. Life Insurance Company of North America[1], the insurer refused to pay claimant her disability benefits. Although claimant saw multiple doctors and psychiatrists for PTSD and depression before filing her disability claim, the court ultimately found that the medical records she submitted were deficient, for several reasons.
First, even though claimant was asserting mental health claims, the claimant’s primary treatment provider was a family practice physician, not a psychologist or psychiatrist. Additionally, the court observed that the family practice physician’s records were “cursory, and contain[ed] minimal documentation of the frequency or intensity of [claimant’s] symptoms.” Id. To make matters worse, the claimant only saw the psychiatrists for a period of a few months, and the psychiatrists’ records showed that claimant had refused to follow the recommended treatment plan, which included both psychiatric medication and cognitive treatment.
The claimant attempted to supplement her medical records using a narrative letter she wrote describing her symptoms, along with several letters from family and friends. However, the court ultimately found the narratives unconvincing because there was a “significant potential for bias,” the severity levels described in the narratives conflicted with the psychiatrists reports, and claimant’s friends and family were not medical specialists or care providers and therefore could not diagnose claimant’s medical condition or assess claimant’s functional capacity. Id.
In the end, the court affirmed the denial of disability benefits, even under de novo review. Id.
What could the claimant have done better to avoid the denial? For one, she could have used a psychiatrist or psychologist as her primary treatment provider. She also could have followed the treatment plan recommended by her psychiatrists. Finally, she could have asked her physician to provide more thorough documentation.
Remember, courts will generally want to see medical records, not statements from friends and family. While such statements can be a useful way to provide background information, a court will want to see documentation of diagnosis and treatment by a health care provider. An experienced disability insurance attorney can help you review your medical records and determine if they are sufficient in comparison to the documentation that the insurance company will almost assuredly be collecting.
[1] No. CV1407955MMMFFMX, 2015 WL 6755187 (C.D. Cal. Nov. 4, 2015).
Disability Insurance Profiles: Principal Life
We are expanding our list of insurance company profiles that specifically market to dentists and doctors to include Principal Life.
See our other profiles of Great-West, MassMutual, MetLife, Northwestern Mutual, Guardian, Hartford, and Standard.
Principal Life (also known as “Principal Financial Group”) was founded in 1879. Initially, Principal Life operated primarily as an insurance company. Principal Life is now a member of the Fortune 500, and offers several additional services, such as retirement and asset management. Principal has most recently realized a growth in net income from $1.112 billion in June of 2014 to $1.290 billion in June of 2015.
Company: Principal Financial Group or The Principal.
Location: Des Moines, Iowa.
Associated Entities: Principal Financial Services, Inc.; Principal Life Insurance Company; Principal Real Estate Investors, LLC; Spectrum Asset Management, Inc.; Post Advisory Group, LLC; Columbus Circle Investors; Edge Management, Inc.; Morley Financial Services Inc.; Finisterre Capital, LLP.
Assets: $530.3 billion.
Notable Policy Features:
Principal Life sells polices that define “disability” as “own occupation”, which means that you are considered totally disabled if you are unable to perform the duties of your occupation. While this may seem like the right policy for a medical professional, you should be aware of a couple caveats. Coverage under a Principal Life policy is, in part, based upon a key definition that is usually referred to as your “occupation period.” Essentially, your “occupation period” is the time frame during which the “own occupation” definition of totally disabled applied. Once the “occupation period” has expired, Principal Life will only pay you benefits if you are unable to work in any occupation that you are reasonably suited to work in, based on your education, training, and experience.
The length of your “occupation period” can range from a base of 2 years after your disability to a period of 5 years, until age 65, until age 67, or until age 70, depending on your “occupation class.” Oftentimes, the policy provisions regarding “occupation periods” can be convoluted and difficult to decipher. If you unsure about the length of your “occupation period” under the terms of the policy, an experienced disability insurance attorney can help you understand the applicable policy language.
Claims Management Approach:
In comparison with other insurance companies, Principal Life generally conducts more in-person field interviews with claimants. Principal Life will not only conduct a field interview when you initially file your claim, but will also likely conduct several additional follow up interviews throughout the claims process.
Most insurance companies require you to fill out generic questionnaires that ask for information about the nature of your disability, among other things. Because Principal Life handles a lot of disability claims by physicians, it has created a particular “Medical Professional Occupation and Financial Questionnaire” that is more comprehensive than a generic questionnaire, and is specifically tailored towards collecting information from medical professionals. The questionnaire is quite extensive, and asks about a wide variety of information, from your ownership interest in your practice, to whether your practice participates in a health care network, to the credentials of the medical professional owners and associate professionals you work with, to whether you receive any reimbursements from prescriptions. If you are unsure about the content or scope of any questionnaire you receive, an experienced disability insurance attorney can help answer any questions you may have.
“Working Through Pain:
How Chronic Conditions Affect Dentists”
Dentists are particularly at risk for disability due to the strenuous nature of their job. Dentists are also some of the most likely to keep working through the pain–even if they shouldn’t be. Our new article in Dentaltown Magazine explores how working through chronic pain can affect dentists in their personal and professional lives. Read the full article at Dentaltown today.
“Working Through Pain: How Chronic Conditions Affect Dentists”
Protecting the Protectors: Depression, Medical Professionals, and the Conflicts Involved with Under-reporting
Today we’re taking a closer look at how depression can affect doctors and dentists, their practices, and the way they file for disability insurance. We examine how the medical community’s approach toward mental health is perhaps preventing some doctors from reporting illness, and how this changes a doctor’s ability to obtain adequate treatment and secure disability insurance benefits.
Depression and anxiety are undeniably prevalent among physicians and dentists. For instance, a study in Australia showed that the rates of depression in doctors is four times higher than the general population and in a British study, 60% of dentists surveyed reported being anxious, tense, or depressed.
Simply looking at the daily life of doctors, and comparing that to the risk factors for depression shows some striking connections between the two. Some of the risk factors associated with depression (as outlined by the Mayo Clinic) include being overly self-critical, having serious or chronic illness and dealing with traumatic or stressful events. Interestingly, these are many things that doctors and dentists struggle with; indeed, probably more often than the average person. Doctors and dentists have to be self-critical because if they aren’t, lives could be at stake. In addition, doctors and dentists often suffer from chronic illness and pain due to the physically and emotionally taxing nature of their work. Worrying about patients, running a practice, and working long hours are all part of the job description for the average doctor.
While physicians and dentists commonly have symptoms of depression, they often don’t report their issues due to the stigma of mental health issues within the medical community. Lay people look to doctors and dentists as the paragon of health, and physicians take the same approach: while their patients are characterized by their illness, physicians are supposed to be the ones who cure them. While the general populace’s approach to mental illness has improved greatly over time (we no longer lock people in tiny jail cells simply because they are mentally ill), the negative stigma attached to depression and anxiety in the medical and dental community is still present. In the Australian study noted above, half of the respondents reported thinking that they were less likely to be appointed to a new position if they had a history of mental illness, and 40% admitted thinking less of doctors that have a history of depression or anxiety.
Nevertheless, it is important for doctors to recognize whether they exhibit signs of mental illness. Aside from needing to be mindful of their own health and well-being, doctors are responsible for the health and well-being of their patients, too. Physicians and dentists both are in the unique position that a mistake that they make at work could endanger a life. Attempting to work through depression and anxiety symptoms that impair the doctor’s ability to provide responsible patient care could lead to a malpractice suit. Perhaps the solution to this issue is a re-evaluation of the medical community’s approach to mental illness. While that seems like a large task to take on, it starts with each individual doctor either seeking treatment for mental health, or supporting those that do.
For physicians, states have programs in place called Physician Health Programs (PHPs) that are supposed to support the health, including mental health, of medical licensees. A PHP is advertised as a way to get the help one needs, while avoiding disciplinary action such as a loss of license. Physicians should be aware, however, that PHPs are often connected to the licensing boards, and non-compliance with the PHP can lead to disciplinary action. For example, in Arizona, while the PHP is operated by an independent agency, it does have a formal contractual relationship with the state licensing board.
Disability Insurer Profiles: Great-West
Great-West Life & Annuity Insurance Company (“Great-West”) is the final disability insurance provider we will look at in our series profiling insurance companies that specifically market to physicians and dentists.
See our profiles of MassMutual, MetLife, Northwestern Mutual, Guardian, Hartford, and Standard.
Great-West, which also goes by the registered mark of “Great-West Financial,” was incorporated in 1907, and traces its roots to a Canadian parent company that was incorporated in 1891. Due to the nature of the economy and other factors, many insurance companies have suffered substantial losses in the past few years, and Great-West is no exception. Great-West’s net income recently dropped from 238.1 million in 2012 to 128.7 million in 2013. Consequently, Great-West may be looking to substantially increase its profits by, for example, denying high paying disability claims.
Company: Great-West Life & Annuity Insurance Company.
Location: Greenwood Village, Colorado.
Associated Entities: Great-West Lifeco Inc.; Great-West Lifeco U.S. Inc.; Great-West Life Assurance Company; Great-West Life & Annuity Insurance Company of New York; Great-West Capital Management, LLC; Great-West Funds, Inc.; GWFS Equities, Inc.
Assets: $55.3 billion in 2013.
Notable Policy Features: Great-West is the insurance company that provides group disability insurance for the American Dental Association (ADA), so if you have a Great-West policy, your claim will probably be governed by the terms of the ADA’s group disability policy.
Great-West frequently sends out notices of updates and changes to the underlying contract between the ADA and Great-West, so there is a chance that you may end up with insurance coverage that you did not bargain for at the point of sale. Oftentimes these notices are full of legalese and insurance jargon, and may be difficult to understand. Nevertheless, it is important for you to promptly review any notices you receive, because they may impact your disability coverage in significant ways. If you receive such a notice and are unsure about what it means, an experienced disability insurance attorney can explain how the changes outlined in the notice will impact your policy.
Additionally, if you have a Great-West policy, you should be aware that your policy may contain a very strict provision requiring you to obtain proper medical care for your condition. For this reason, if you are thinking about filing a disability claim with Great-West, you should make sure that your medical treatment is both well-documented and “appropriate” under the policy’s terms.
Claims Management Approach: How Great-West administers your disability claim will depend on the terms of the policy at the time you file your claim. Because the terms of the ADA’s group disability policy are renegotiated on a regular basis, the terms of your disability policy will likely change over time. Since your initial copy of the policy may no longer be accurate by the time you file your disability claim with Great-West, be sure to ask for a copy of the current version of your policy so that you know your rights under your disability insurance policy.
These profiles are based on our opinions and experience. Additional source(s): Great-West Financial’s 2013 Annual Report; www.greatwest.com.
Disability Insurer Profiles: Standard
Standard is another disability insurer we will look at that specifically markets its policies to physicians and dentists.
See our profiles of MassMutual, MetLife, Northwestern Mutual, Guardian, and Hartford.
StanCorp Financial Group (“StanCorp”) was founded in 1906 and uses the marketing name “The Standard” to refer to its primary subsidiaries, which include the Standard Insurance Company and the Standard Life Insurance Company of New York. In 2013, StanCorp received $351.7 million in pre-tax income, and $272.4 million (approximately 77%) of that income was attributable to profits from StanCorp’s insurance services. StanCorp is particularly proud of its consistent long term growth and—given the fact that 77% of StanCorp’s profits come from its insurance services—StanCorp has an obvious incentive to deny high paying disability claims submitted by physicians and dentists.
Company: StanCorp Financial Group, Inc.
Location: Portland, Oregon.
Associated Entities: Standard Insurance Company; The Standard Life Insurance Company of New York; StanCorp Investment Advisers, Inc.; Standard Retirement Services, Inc.; StanCorp Mortgage Investors, LLC.
Assets: $22.73 billion in 2014.
Notable Policy Features: If you are considering a Standard disability insurance policy, you should pay particular attention to whether the policy allows for total disability benefits if you are working in another occupation. Oftentimes, Standard policies will pay nothing more than residual disability benefits if you are able to secure other part-time employment. For example, if you can no longer practice dentistry, but you are able to teach classes at a dental college, Standard may refuse to pay you total disability benefits. If you are eligible for residual benefits, Standard will require you to submit proof of your income every single month.
Read more about the difference between total disability benefits and residual disability benefits.
Claims Management Approach: Standard tends to demand strict compliance with its claims procedures, and Standard will generally not be very accommodating if you make a mistake. This can be problematic, because, for many policyholders, the disability claims process is unfamiliar and daunting. If you are dealing with Standard, be sure to ask for a detailed explanation of what is required of you. You should pay close attention to deadlines, as they will likely not be flexible. You should also make sure that you use Standard’s forms when providing attending physician statements or other documentation of your disability, because Standard will not accept other insurers’ forms.
These profiles are based on our opinions and experience. Additional source(s): “Quick Facts About the Standard” and “About the Standard,” available at www.standard.com; StanCorp 2014 KBW Conference Presentation, available at investor.stancorpfinancial.com.
Disability Insurer Profiles: Hartford
Hartford is the next disability insurer we will look at that specifically markets its disability policies to physicians and dentists.
See our profiles of MassMutual, MetLife, Northwestern Mutual, and Guardian.
The Hartford Financial Services Group, Inc. (“Hartford”) was founded over 200 years ago and now has more than 100 offices located throughout the U.S. In 2013, Hartford’s revenues were approximately $26.2 billion. However, in 2014, Hartford’s revenues dropped to $18.6 billion. Given this significant decrease in revenue, Hartford will likely go to great lengths to avoid paying high paying claims submitted by physicians and dentists, and may even attempt to revoke disability benefits that it approved before the company experienced this dramatic drop in profits.
Company: The Hartford Financial Services Group, Inc.
Location: Hartford, Connecticut.
Associated Entities: Hartford Fire Insurance Company; Hartford Life, Inc.; Hartford Accident and Indemnity Company; Hartford Casualty Insurance Company; Hartford Life and Accident Insurance Company; Hartford Life and Annuity Insurance Company; Hartford Life Insurance Company; Property and Casualty Insurance Company of Hartford.
Assets: $245 billion in 2014.
Notable Policy Features: Hartford offers disability insurance policies that define total disability as being unable to perform one of your prior substantial and material duties. If your disability policy contains such a definition, it will be much easier for you to demonstrate that you are totally disabled. In contrast, if your disability policy does not define total disability in this manner, you may have to prove that you cannot perform any of your prior substantial and material duties in order to receive total disability benefits.
Claims Management Approach: Hartford only offers group disability policies (as opposed to individual disability policies). This means that if you have a Hartford policy, it will probably be governed by ERISA. For many reasons, it will likely be harder for you to obtain your disability benefits if your policy is governed by ERISA.
For example, normally, if you become disabled and you have an individual disability policy, you can collect your disability benefits without filing for Social Security. However, if you have a Hartford group policy, your policy may require you to apply for Social Security benefits before you can receive your disability benefits. Hartford requires its policyholders to apply for Social Security because, under ERISA, any Social Security benefits the policyholder receives automatically offset the amount of disability benefits Hartford must pay the policyholder.
Read more about how ERISA claims are treated differently than non-ERISA claims.
These profiles are based on our opinions and experience. Additional source(s): Hartford’s 2014 Annual Report; “The Hartford Fact Sheet (2013),” and “The Hartford Fact Sheet (2014),” available at www.thehartford.com.
Disability Insurer Profiles: Guardian
In the last few posts, we’ve looked at a few of the most common disability insurance companies for doctors. See our profiles of MassMutual, MetLife, and Northwestern Mutual. Guardian is another disability insurer that specifically markets its disability policies to physicians and dentists.
Guardian has been around for over 150 years and is one of the largest individual disability income insurance providers in the United States. Guardian’s business model emphasizes the need for continuous growth, and Guardian reports that it has paid out dividends to its owners every year since 1868. To reach its goal of uninterrupted growth and live up to its owners’ expectations that it will pay out dividends each year, Guardian must not only maintain its past levels of profitability, but also come up with new ways to be more profitable. Obviously, from Guardians’ perspective, denying high paying disability claims submitted by physicians and dentists is an attractive method of increasing its profits.
Company: The Guardian Life Insurance Company of America.
Location: New York, New York.
Associated Entities: The Guardian Insurance & Annuity Company, Inc.; Berkshire Life Insurance Company of America; Guardian Investor Services, LLC; Park Avenue Securities LLC; RS Investment Management Co. LLC; Reed Group, Ltd.
Assets: $84.1 billion in 2013.
Notable Policy Features: Guardian policies oftentimes attach a “Residual Disability Rider” to their disability policies. This rider could impact you in significant ways if you are partially disabled and considering part-time work. For instance, the residual disability rider to your policy might contain the following provisions:
“Income. Income means your gross earned income, less business expenses, but before any other deductions. It includes salaries, wages, fees, commissions, bonuses, business profits or other payments for your personal services.”
“Prior Income. Prior income means your average monthly income for the tax year with the highest earning in the three years just prior to the date on which you became disabled.”
“Current Income. Current income means all income which you receive on a cash basis in each month while you are residually disabled.”
“Loss of Income. Loss of income means the difference between your prior income and your current income.”
“Residual Indemnity. Residual indemnity = (loss of income/prior income) x monthly indemnity.”
“Termination of Residual Indemnity. Residual indemnity will stop when the first of the following events occurs:
- you become totally disabled; or
- the benefit period ends; or
- your loss of income is less than 20% of prior income . . . .”
When read together, these provisions essentially mean that if you are partially disabled and working in another occupation, Guardian includes the additional income earned in that occupation when determining your current monthly income. This is important because you could lose your residual disability benefits if, after adding in your additional income, your loss of income amounts to less than 20% of your prior income. If you have this residual rider in your disability insurance policy, you should be aware that accepting part time work could jeopardize your ability to collect residual disability benefits.
Read more about residual disability benefits.
Claims Management Approach: Like many of the other insurance companies we have profiled, Guardian frequently conducts in-home field interviews, in an effort to catch you off guard and observe you in a state of activity that may not accurately reflect the severity of your condition. In-home field interviews also allow Guardian to collect personal information, such as your daily routine, hobbies and interests, names of friends and family, and work hours, so that its private investigators can more easily conduct surveillance of you.
If your disability claim involves a psychological disability, Guardian will likely require you to submit proof that you are being treated by a PhD level therapist, even if you have been working with a non-PhD level therapist for a significant period of time. Consequently, if you have a Guardian disability insurance policy and are in need of therapy, you might want to consider consulting with a PhD level therapist from the start.
A final tactic frequently used by Guardian is the peer-to-peer call, which consists of Guardian directly contacting your treatment providers over the phone without your consent. This tactic is similar to the in-home field interview in the sense that it is an attempt to catch your treating physicians off-guard by ambushing them with detailed questions about your disability. Since these discussions take place over the phone, your treating physicians will likely not have an opportunity to provide well thought out, thorough answers, and there will likely be little, if any, documentation of the call. Although this tactic is alarming, it is easily countered. As we explained in a previous post, peer-to-peer calls can be preempted in most cases if you have your disability insurance attorney notify the insurance company that all communications with your treatment providers must be coordinated through your attorney’s office.
These profiles are based on our opinions and experience. Additional source(s): Guardian’s 2013 Annual Report; Guardian Fact Sheet 2013; guardianlife.com.
Disability Insurer Profiles: Northwestern Mutual
In this series, we’re taking a look at some of the most popular disability insurance companies for doctors. See our profiles of MassMutual and MetLife. Northwestern Mutual is another disability insurer that specifically markets its disability policies to physicians and dentists.
In 2014, the company insured 476,000 people through 727,000 individual disability policies. Northwestern Mutual prides itself on paying more dividends that its competitors. In order to do that, of course, it must maintain consistently high profit levels.
Company: Northwestern Mutual Life Insurance Company.
Location: Milwaukee, Wisconsin.
Associated Entities: Northwestern Long Term Care Insurance Co., Northwestern Mutual Investment Services, LLC, Northwestern Mutual Wealth Management Co., The Frank Russell Co.
Assets: $217.1 billion in 2014.
Notable Policy Features: Northwestern Mutual sells policies with an “own occupation” definition of total disability. However, these disability insurance policies are often only truly “own occupation” for a limited amount of time, after which they become any occupation policies (only providing benefits if you are unable to work in any job) or “no work” own occupation policies (only providing benefits if you are unable to perform your job duties and are not working in another job).
For instance, a Northwestern Mutual policy might include the following definition:
Total Disability. Until the end of the Initial Period [defined elsewhere as 60 months of benefits], the Insured is totally disabled when is unable to perform the principal duties of his occupation. After the Initial Period [i.e., 60 months], the Insured is totally disabled when he is unable to perform the principal duties of his occupation and is not gainfully employed in any occupation.
In order to make sure a Northwestern Mutual disability insurance policy keeps the own occupation definition for as long as you hold the policy, you may need to purchase an additional benefit rider.
Read more about Northwestern Mutual’s interpretation of its own occupation policies.
Claims Management Approach: Some of the claims strategies that Northwestern Mutual is known to use include conducting in-home field interviews on top of third-party surveillance, hiring its own medical consultants to review claimants’ records and opine on whether or not they are disabled, and demanding that claimants (especially those with mental conditions) undergo “independent” medical examinations (IMEs) with providers of Northwestern Mutual’s choosing.
These profiles are based on our opinions and experience. Additional source(s): Northwestern Mutual’s 2013 Annual Report; Northwestern Mutual Fact Sheet 2014; Forbes.com.
Field Interviews: What to Expect After the Interview Ends
We’ve discussed why a disability insurer might want to schedule a field interview and what to expect before and during the interview itself. Now we review what claimants can expect can expect after the interview ends. Again, the process is usually different depending on whether not a disability insurance attorney is involved.
After the Field Interview
After your interview ends, the field representative will leave to do some additional reconnaissance. Without telling you, the representative may drive to your office to talk to people on your staff. He or she will see what the office looks like, if it’s busy, and whether your name is still listed on the door. If you have a disability insurance attorney, the attorney will have discussed this with you ahead of time, and together you will have taken steps to make sure the representative doesn’t bother your staff or catch them off guard.
Some days after the field interview, the representative will send you a copy of his or her report, which purports to summarize your conversation. The report will ordinarily be 8 to 10 pages or more. He or she will ask you to review the report, make any changes you see fit, and return it. The representative will advise that if you don’t make any changes by a certain date, he or she will assume that everything in the report is accurate.
For claimants with legal representation, the report will be sent to your attorney’s office. Your attorney will review the report to make sure that it accurately reflects the facts of your disability claim. He or she should be able to correct any seemingly harmless statements that a claims adjuster may take out of context to support denying or terminating your disability claim. If any important information is missing, your attorney will make sure to include it along with the report.
Meanwhile, the field representative will usually send a separate report to the insurance company. This second report will have the representative’s personal observations about you, their conversations with your staff, and any other information he or she was able to gather about your outside of the interview. You will not be provided with a copy of this report unless you’re able to obtain the claim file after your disability claim has been terminated or denied. If you have an attorney, this second report will be much more limited, as the representative will not have had the opportunity to visit your home or to pry into irrelevant or confidential information. If your disability claim is denied or terminated, your attorney will obtain and review this report for any inaccuracies or misstatements.
A field interview can be intimidating, but knowing why the interview is being conducted and what to expect during the process can make you better prepared to handle it in a way that doesn’t prejudice your claim. If you have questions or concerns about a field visit, contact a disability insurance lawyer right away.
Field Interviews:
What to Expect Before and During the Interview
Our last post discussed why an insurance company might want to conduct a field visit or field interview. Now that you know what the insurer is trying to accomplish, we’ll discuss what exactly to expect before the interview, during the interview, and afterwards. As with many aspects of the disability claims process, the field interview will be different depending on whether or not you have a disability insurance attorney involved. First, what to expect before and during the interview:
Setting Up the Field Interview
Initially, the field representative will call or e-mail you personally to set up a time to meet. He or she will ask to come to your home, or sometimes your office (particularly if you have been practicing as a dentist or physician), and talk one-on-one. If you’re being represented by a disability insurance lawyer, the field representative will call or write a letter to the lawyer’s office to request a field interview. Your attorney will evaluate whether the in-person interview is necessary and appropriate under the terms of your policy and your particular claim situation. If so, your attorney will likely ask the field interviewer to meet at the attorney’s office, rather than in your home or office. Your attorney, and sometimes an assistant as well, will attend the interview. The attorney and/or his or her assistant will take careful notes of the entire conversation.
During the Field Interview
When the representative arrives, he or she may ask to take your photograph. The representative may also ask to audio-record your conversation. If an attorney is present, the representative will usually refrain from asking to take a photograph or audio-record the conversation, knowing that your legal counsel will likely determine it unnecessary and/or inappropriate.
The field representative will sit down and talk with you for an hour or more. He or she will have an extensive list of questions to ask you, most of which your claims analyst will have specifically requested the representative address. For those with legal representation, your attorney will have prepared you for each of the questions the representative will ask, so you’ll be ready to give accurate and well-considered answers.
During your conversation, the representative will be very warm and friendly. The representative will normally try to establish a rapport so that you’ll relax and talk openly. He or she will try to get you to talk without thinking, encourage you to go into unnecessary detail, and may ask personal questions that a claims adjuster would normally avoid.
The representative often acts somewhat more reserved when a disability insurance attorney is present. Field representatives know that if they ask any questions that are irrelevant, seek confidential information, or are otherwise inappropriate, your attorney will intervene and let you and the representative know that you don’t need to answer the question.
While you’re talking, the field interviewer will take copious notes. These notes will include the interviewer’s own observations about your appearance, how well you move, how long you were able to sit or stand, what your house looks like (if in your home), and whether you seem nervous or not. If your attorney attends, the representative will know that his or her notes will be compared against the attorney’s, so he or she will be especially careful to document the circumstances accurately.
In our next post, we’ll talk about what happens after the field interview ends.
