Reading through contracts, especially lengthy insurance ones, can be time consuming. Many policies contain confusing language, terms of art, and often include supplemental riders that change the terms or definitions contained in the main body of the policy. But if you don’t read your policy until it’s time for you to file a claim, you may be caught off-guard by what your policy actually says. This next series of posts will discuss the importance of taking the time to read through your policy, and will review some things to watch out for when you buy a disability insurance policy.
Dentists and physicians are often swamped with work, and rely heavily on insurance agents when selecting and purchasing a policy. One scenario we commonly see is doctors requesting a policy that is “the same” policy that the other doctors in the practice have. Another common scenario is the doctor who wants more coverage and just asks his or her agent for another policy that is “like” his or her existing policy, or has the “same coverage” as his or her existing policy. What they don’t realize is that some of the same favorable terms may no longer be available in today’s policies. For example, while most older policies contained “true own occupation” provisions, there are now several different variations of “own occupation” provisions, so if you just ask for an “own occupation” policy, you may not actually be receiving the coverage that you think you are.
It is also important to be aware that, over the years, insurers have sought to distance themselves from agents and now often go so far as to include clauses or statements in their policies and applications that state no agent or broker has the authority to determine insurability or make, change, or discharge any contract requirement. Here’s an example of this type of policy language:
So what does this mean? It means that, while solely relying upon an agent’s assurance of the terms of a policy may have been a more acceptable (but not advisable) option in the past (when policies were often similar and generally favorable to policyholders), you can no longer solely rely upon your agent’s description of the policy. No matter how well-meaning or knowledgeable your agent may seem, ultimately, you are going to be on the hook if your policy doesn’t say what you thought it said, so it is crucial that you carefully review your disability policy to ensure you are receiving sufficient coverage.
Our next post will discuss the importance of the application process and policy review period.
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.
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.
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
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
Migraines have been shown to co-occur with several other conditions, including:
- Cardiovascular disorders, coronary heart disease, and hypertension
- Psychiatric disorders (anxiety, depression, bipolar disorder)
- Restless leg syndrome
- Chronic pain such as musculoskeletal pain
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)
- Transcutaneous supraorbital nerve stimulation (t-SNS)
(a headband-like device with attached electrodes)
- Massage therapy
- Cognitive behavioral therapy (CBT)
- Herbs, vitamins, and minerals
- Relaxation exercises
- Sticking to a sleep schedule
- 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.
Mayo Clinic, www.mayoclinic.org
 Migraine Research Foundation, About Migraine, http://migraineresearchfoundation.org/about-migraine/migraine-facts/
 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
 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).
Ed Comitz, one of the firm’s founding members, was recently named as a Top Lawyer in the field of insurance law in Phoenix Magazine’s special, 50th Anniversary Issue.
Mr. Comitz’s practice primarily focuses on helping physicians and dentists secure private disability insurance benefits. Mr. Comitz and the legal team at Comitz | Beethe also represent doctors in several other areas, including practice transitions, employment law, business litigation, estate planning, regulatory compliance, and licensing issues.
In previous posts, we have been looking at the findings from the most recent study on long term disability claims conducted by the Council for Disability Awareness. In this post we will be looking at the types of diagnoses associated with long term disability claims, and which types of claims are most common.
As you can see from the chart above, the most common type of both new and existing long term disability is musculoskeletal disorders—a category which includes neck and back pain caused by degenerative disc disease and similar spine and joint disorders.
This is particularly noteworthy because physicians and dentists, who often have to maintain uncomfortable static postures for several hours each day, are very susceptible to musculoskeletal disorders. In addition, claims involving musculoskeletal disorders can be challenging, because oftentimes there is little objective evidence to verify the pain. If you suffer from degenerative disc disease or a similar disorder, an experienced disability attorney can explain how to properly document your claim to the insurance company.
In the last post, we discussed the facts of the court case Massachusetts Mutual Life Insurance Company v. Jefferson. In that case, the court was asked to determine whether a clinical psychologist whose license had been suspended was entitled to disability benefits. In this post, we will discuss how the court ultimately ruled, and go over some takeaways from this case.
The Court’s Ruling
As explained in the last post, the key question was whether Dr. Jefferson’s legal disability (i.e. the suspension of his license to practice psychology) happened before the onset of Dr. Jefferson’s factual disability (i.e. his depression). In the end, the court determined that Dr. Jefferson was not entitled to disability benefits for the following reasons:
- Dr. Jefferson’s claim form stated that he was not disabled until April 29, 1990, which was two days after the licensing board revoked his license.
- Although Dr. Jefferson later claimed that his depression went as far back as May 1989, the court determined that such claims were inconsistent with:
- Jefferson’s representations to the licensing board that he was a “highly qualified and competent psychologist”;
- The fact that Dr. Jefferson had been consistently seeing patients up until the day his license was revoked; and
- The fact that Dr. Jefferson had scheduled patients during the month following the licensing board’s hearing.
Thus, under the circumstances, the evidence showed that Dr. Jefferson’s was not entitled to benefits because his legal disability preceded his factual disability.
Dr. Jefferson’s case provides a good example of the challenges that can arise in a disability claim if the claimant has lost his or her license. Here are some of the major takeaways from this case:
Be Precise When Filling Out Claim Forms. The date you list as the starting date of your disability can be very significant. Take your time when filling out claim forms, and make sure that the date you provide is accurate and consistent with the other information you are submitting with your claim forms. It is always a good idea to double check everything on the form at least once after you have completed it, to make sure that you did not make a mistake.
Recognize that Your Claim Will Not Be Evaluated in a Vacuum. Other proceedings—such as board hearings—can directly impact your claim. You should always assume that anything you say in such a proceeding will at some point end up in front of the insurance company. This is particularly problematic when, as in Dr. Jefferson’s case, the goals of the other proceeding are inconstant with the goals of the disability claim. In such a situation, you may have to decide which goal is more important to you. An experienced attorney can help you assess the strengths and weaknesses of each available option so that you can make an informed decision.
Do NOT Engage in Activities that Place Your License in Jeopardy. Losing a license that you worked hard for several years to obtain is not only emotionally devastating, it can severely limit your options going forward. Even if you have a disability policy, it is very difficult to successfully collect on a disability claim if your license has been revoked or suspended. Once again, if you find yourself in Dr. Jefferson’s position, you should talk with an experienced attorney who can help you determine what your available options are, if any.
 104 S.W.3d 13, 18 (Tenn. Ct. App. 2002).
In the last post, we discussed the distinction between “factual” and “legal” disability and why that distinction matters. In this post, we will begin looking at a court case involving “factual” and “legal” disability. Specifically, in this post we will begin looking at the facts of the case and the test that the court applied. In Part 3, we will see how the court ultimately ruled.
In the case of Massachusetts Mutual Life Insurance Company v. Jefferson, the court assessed whether Dr. Jefferson—a clinical psychologist—was entitled to disability benefits. Here are the key facts of the case:
- From October 1987 to February 1989, Dr. Jefferson had an affair with a former patient.
- When Dr. Jefferson’s wife found out about the affair, she filed a complaint with Dr. Jefferson’s licensing board.
- During the hearings in front of the licensing board, Dr. Jefferson argued that he was a competent psychologist, and that he should be permitted to continue to see patients.
- On April 27, 1990, the licensing board permanently revoked Dr. Jefferson’s license to practice psychology, effective as of May 15, 1990. On appeal, a chancery court reduced the permanent revocation to an eight year suspension ending on May 15, 1998.
- Up until the day his license was revoked, Dr. Jefferson continued to see patients and schedule future patients.
- On October 1, 1900, Dr. Jefferson filed a claim under his disability policy, claiming that he was disabled due to “major depression.”
- On his claim form, Dr. Jefferson listed the beginning date of his disability as April 29, 1990. Later on, Dr. Jefferson attempted to submit evidence that he had been depressed as early as May 1989.
The Court’s Test
As a threshold matter, the Court determined that the suspension of Dr. Jefferson’s license was a “legal disability” and assumed for the sake of argument that Dr. Jefferson’s “major depression” was a “factual disability.” As explained in Part 1 of this post, courts generally hold that disability policies only cover factual disabilities, not legal disabilities. However, the court’s decision becomes more difficult when a claimant like Dr. Jefferson has both a legal disability and a factual disability.
Although different courts approach this situation in different ways, here is the test that the court came up with in Dr. Jefferson’s case:
- Step 1: Determine which disability occurred first.
- Step 2: Apply the following rules:
- Rule # 1: If the legal disability occurred first, the claimant is not entitled to benefits.
- Rule # 2: If the factual disability occurred first, the claimant is entitled to benefits, if the claimant can prove the following three things:
- The factual disability has medical support.
- The onset of the factual disability occurred before the legal disability.
- The factual disability actually prevented or hindered the claimant from engaging in his or her profession or occupation.
In the next post, we will discuss how the court decided this case. In the meantime, now that you have the key facts and the court’s test, see if you can guess how the court ultimately ruled.
 104 S.W.3d 13, 18 (Tenn. Ct. App. 2002).
In the next few posts we will be looking at the distinction between “factual” and “legal” disability. In Part 1, we will discuss the difference between a factual and a legal disability, and why that distinction matters. In Parts 2 and 3, we will look at an actual court case involving “factual” and “legal” disability.
What is “Factual Disability”?
Factual disability refers to incapacity caused by illness or injury that prevents a person from being physically or mentally able to engage in his or her occupation. This is the type of disability that most people think of in connection with a disability claim.
What is “Legal Disability”?
Legal disability is a broad term used to encompass all circumstances in which the law does not permit a person to engage in his or her profession, even though he or she may be physically and mentally able to do so. Here are some examples:
- Revocation or suspension of a professional license;
- Surrendering a professional license as part of a plea agreement or to avoid disciplinary action; and
- Practice restrictions imposed by a licensing board.
Why the Distinction Matters
In sum, someone with a “factual disability” is mentally or physically unable to engage in their profession. In contrast, someone with a “legal disability” is not allowed to engage in their profession. Courts have repeatedly held that disability insurance policies provide coverage for factual disabilities, but not for legal disabilities.
If a claimant has both a factual and legal disability, things become more complicated. In the next few posts, we will look at an example of how one court determined whether someone with both a factual and legal disability was entitled to benefits.
Recently, several disability insurers have started to introduce new online applications in an effort to make purchasing disability insurance more convenient. Some of them even offer automated underwriting and instant approval of your application. In connection with the online applications, insurers are also providing more flexible options regarding benefit amounts and benefit periods.
While online applications will likely make purchasing disability insurance more convenient, here are some tips to keep in mind and some pitfalls to avoid.
- Don’t neglect to shop around. While it will certainly take less time to just apply to the first website you come across, you should always look at what multiple companies are offering before you apply for disability benefits. While it may not seem like it at the time, the decision to purchase disability insurance may be one of the most important decisions in your life if you end up becoming disabled. So make sure to take the time to research what your options are, so that you can be sure to get the best policy you are able to.
- Do the research. If you are merely interacting with a computer screen, you will not be able to ask questions about particular policy provisions. Consequently, you should take the time to do outside research so that you know exactly what to look for and what to avoid in a policy.
- Don’t sacrifice important provisions for convenience or affordability. There are certain provisions that every doctor and dentist should have in their policy, such as an own occupation provision. If the online policy does not offer the provisions you need, don’t settle for the sake of convenience or affordability. Remember, if you end up becoming disabled, you will not just want any policy—you will want the best policy.
- Take your time when you are filling out your application. Most insurance policies contain language that allows the insurer to void the policy if you make material misstatements in your application. Many people tend to rush through online applications, particularly if their priority is convenience. Make sure that you double check your answers before you submit the application, to ensure that everything you are submitting is accurate.
- Periodically reevaluate your coverage. If your initial goal is affordability, make sure that you periodically reevaluate your coverage to ensure that it is still sufficient for your needs. Many people initially apply for low benefit policies and neglect to increase their benefits amounts later on when they can afford to pay higher premiums. Consequently, if they become disabled, their benefit amount ends up covering only a small fraction of their prior income.
These tips are particularly important for physicians and dentists to remember when applying for disability insurance, because insurance companies are particularly aggressive towards claims by doctors and dentists. Additionally, many doctors and dentists are accustomed to a high level of income. Physicians and dentists who do not purchase enough coverage and later become disabled can find themselves unable to meet their obligations and care for their family, even if their disability claim is approved. Additionally, as we have discussed in previous posts, in some cases, a single word in a policy can determine whether you receive benefits.
So remember, purchasing disability insurance is not something that should be taken lightly. Take your time, and get the best policy you can.
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 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 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:
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:
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.
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.
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.
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.
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 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 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 insurer is acting in bad faith.
In Part 1 of this post, we discussed “stingrays”—a relatively new technology that is becoming more and more common. In Part 2, we will be discussing another new technology that is becoming increasingly prevalent as a surveillance tool—drones.
What is a “Drone”?
The term “drone” is a broad term that refers to aircrafts that are not manned by a human pilot. Some drones are controlled by an operator on the ground using remote control. Other drones are controlled by on-board computers and do not require a human operator. Drones were initially developed primarily for military use. Recently, drones have also been utilized for a wide range of non-military uses, such as aerial surveying, filmmaking, law enforcement, search and rescue, commercial surveillance, scientific research, surveying, disaster relief, archaeology, and hobby and recreational use.
How Does Drone Surveillance Work?
Typically, drones are connected to some type of control system using a data link and a wireless connection. Drones can be outfitted with a wide variety of surveillance tools, including live video, infrared, and heat-sensing cameras. Drones can also contain Wi-Fi sensors or cell tower simulators (aka “stingrays”) that can be used to track locations of cell phones. Drones can even contain wireless devices capable of delivering spyware to a phone or computers.
Over the past few years, several new methods of surveillance have been developed. These new technologies create a high risk of abuse, and as they become more and more commonplace and affordable, that risk will only increase. Unfortunately, in the area of surveillance, the law has not always been able to keep up with the pace of technology. In many respects, the rules regarding the use of new surveillance technologies remain unclear. Consequently, the most effective way to guard against intrusions of privacy is to be aware of the expanding abilities of existing technology, because you never know when someone could be conducting surveillance.
ACLU Website: https://theyarewatching.org/technology/drones.
In previous posts, we have discussed how insurance companies will hire private investigators to conduct surveillance on disability claimants. In the next two posts, we will be discussing some modern surveillance technologies that most people are not very familiar with – “stingrays” and drones.
What is a “Stingray”?
A “stingray” is a cell site simulator that can be used to track the location of wireless phones, tablets, and computers—basically anything that uses a cell phone network.
How Does Stingray Surveillance Work?
A “stingray” imitates cell towers and picks up on unique signals sent out by individuals attempting to use the cell phone network. The unique signal sent out is sometimes referred to as an International Mobile Subscriber Identity (IMSI) and it consists of a 12 to 15 digit number.
Once the “stingray” connects to a device’s signal, it can collect information stored on the device. Usually the information collected is locational data, which is then used to track the movement of individual carrying the device.
Additionally, some “stingray” devices can intercept and extract usage information, such as call records, text messages, and Internet search history, from devices it connects to. Some “stingrays” are even able to intercept phone call conversations and deliver malicious software to personal devices.
Stay tuned for Part 2, where we will discuss drone surveillance.
ACLU Website: https://theyarewatching.org/technology/stingray.
In Part 1, we looked at how 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 policy.
Note also that this particular provision provides that any month in which benefits are paid counts against the 24 month limit. So, for example, if you received 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 benefits.
When purchasing a 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 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 under your policy.
In previous posts, we have discussed how many disability policies contain mental disorder and/or substance abuse exclusions that either prevent claimants from collecting 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 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 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 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 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.
The most recent study conducted by the Council for Disability Awareness shows that long term disability claim approvals have declined in recent years:
In addition, 50% of the companies surveyed reported increased claim termination rates.
The companies surveyed included:
- AIG Benefit Solutions
- American Fidelity
- Assurant Employee Benefits
- Disability RMS
- The Hartford
- Illinois Mutual
- Lincoln Financial Group
- MassMutual Financial Group
- Ohio National
- Principal Financial
- The Standard
- Sun Life Financial