Cubital Tunnel Syndrome

In previous posts, we’ve discussed several chronic conditions that can affect dentists in particular, as their jobs require them to hold unnatural, static positions for extended periods of time while continuously gripping instruments. This puts tremendous stress on their musculoskeletal systems, especially their hands, and this is, in part, why dentists experience nearly four times the prevalence of hand, wrist and arm pain found in the general public.

While most dentists and surgeons are likely familiar with carpal tunnel syndrome, there are other conditions affecting the hands that can be just as debilitating. In this post we will examine the causes, diagnosis, symptoms, and treatment of cubital tunnel syndrome, a similar condition that arises from nerve impingement at the elbow.

Overview

Cubital tunnel syndrome is a condition that involves pressure or stretching of the ulnar nerve (also known as the “funny bone” nerve) that runs in a groove on the inner side of the elbow. This can cause numbness or tingling in the ring and small fingers, pain in the forearm, and/or weakness in the hand. Those suffering from cubital tunnel syndrome can find it difficult or impossible to function with the same level of dexterity that they used to have.

Causes

Cubital tunnel syndrome occurs when the ulnar nerve becomes compressed or irritated at the elbow, but the exact cause of this is often unknown. There are several factors that can lead to nerve irritation such as:

  • Keeping your elbow bent for long periods of time
  • Repeatedly bending your elbow
  • Leaning on your elbow for long periods of time
  • Repetitive activities that require the elbow to be flexed
  • Prior fractures or dislocations of the elbow

Diagnosis

In order to diagnose cubital tunnel syndrome, a physician will perform a medical history review and physical examination. The examination will include an evaluation of the sensation of the hand and fingers as well as a test of your elbow reflex. Additional screening may be required, including:

  • X-rays: to check for bone spurs, arthritis, or other places that the bone may be compressing the nerve
  • Nerve conduction studies: to determine how well the nerve is working and to help identify where it is being compressed
  • Electromyogram: a test that measures the electrical discharges produced in the muscles

Symptoms

Generalized symptoms of cubital tunnel syndrome include:

  • Numbness and tingling in the ring finger and pinky finger, usually occurring when the elbow is bent (such as when driving or holding a phone)
  • Feeling of pins and needles or the feeling of the hand “falling asleep” in the ring and pinky finger
  • Weakening of the grip and difficulty with finger coordination, especially when manipulating objects

Severe symptoms can include:

  • Weakness in the ring and little fingers
  • Decreased hand grip
  • Muscle wasting in the hand
  • Curling up of the pinky and ring finger along with pain, or a claw-like deformity of the hand

Treatment

Mild symptoms of cubital tunnel syndrome can be managed with home remedies such as:

  • Avoiding activities that require you to keep your arm bent for long periods of time
  • Avoiding leaning on your elbow or putting pressure on the inside of your arm
  • Keeping your elbow straight at night when sleeping by wrapping a towel around your elbow or wearing an elbow pad backwards
  • Performing nerve gliding exercise

More severe cases of cubital tunnel syndrome may require medical interventions such as:

  • Use of non-steroidal anti-inflammatory drugs (NSAIDs) to reduce swelling around the nerve
  • Use of corticosteroids
  • Bracing or splinting
  • Surgery to increase the size of the cubital tunnel or to transpose the nerve in order to relieve the pressure

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

References:

American Society for Surgery of the Hand, http://www.assh.org

American Academy of Orthopaedic Surgeons, https://orthoinfo.aaos.org/

Mayo Clinic, www.mayoclinic.org

WebMD, www.webmd.com

Healthline, www.healthline.com

Dental Products Report, dentalproductsreport.com

Multiple Sclerosis

Multiple sclerosis (MS) is a disease of the central nervous system, which is made up of the brain, spinal cord, and optic nerves. It’s estimated that 2.3 million people worldwide have MS.  In this post we’ll examine the symptoms, causes, diagnosis, and treatment of this disease.

Overview

With MS, the immune system begins to attack the protective sheath, called myelin, that covers the nerve fibers.  The result is faulty communication between the brain and the rest of the body.  The disease may eventually cause the nerves deteriorate and they may even become irreversibly damaged.

The symptoms experienced and the rate of progression and severity of the disease will vary greatly from person to person.  Some individuals may have a very minor form of MS, while others will go on to become paralyzed, or, in rare instances, have a potentially fatal form that progresses rapidly from onset.

MS has several difference courses, in terms of how the disease progresses:

Relapse-Remitting MS: Most people with MS experience times of new symptoms, or relapses, that develop in a relatively short period of time followed by periods remission where there are few or no symptoms.

Secondary-Progressive MS: About 60 to 70% of people with relapse-remitting MS type will go on to experience a steady progression of symptoms.

Primary-Progressive MS: Some individuals have a gradual onset and progression of symptoms without relapses.

Benign MS: MS is considered benign if the individual has no relapses and a mild, stable disability after about 15 years from the time of diagnosis.

Symptoms 

Because MS attacks the central nervous systems, a wide range of symptoms in nearly any function can occur.  Symptoms will also vary in type and severity from one person to another.  Symptoms can resolve, come and go, or be permanent. Common symptoms include:

  • Blurred vision
  • Partial or complete loss of vision
  • Loss of balance
  • Poor coordination
  • Dizziness or vertigo
  • Slurred speech
  • Tremors
  • Tingling
  • Electric shock sensations
  • Numbness or weakness
  • Extreme fatigue
  • Depression
  • Temperature sensitivity
  • Memory and concentration problems
  • Paralysis

Causes and Risks Factors 

While the cause of MS is unknown, many believe it is a mix of genetics and environmental factors.  Scientists have identified several risk factors that may be associated with MS:

  • Genetics and family history
  • Gender (women are 2 to 3 times more likely to develop MS)
  • Age (most people are diagnosed between the ages of 20-50)
  • Certain infections, including the Epstein-Barr virus
  • Certain autoimmune diseases, including type 1 diabetes or thyroid disease
  • Smoking

Diagnosis 

MS is often a hard disease to diagnose, especially because symptoms vary from person to person, can come and go, and are similar to other disorders of the nervous system.  While there is no single diagnostic test, there are several methods physicians use to evaluate individuals for MS, including:

  • Blood tests to screen for other diseases with similar symptoms (e.g. Lyme disease)
  • Balance, coordination, vision, and other tests to see how the nerves are functioning
  • MRIs to detect changes in the brain (lesions) and/or spinal cord
  • Evoked potentials tests, which evaluate electrical activity in the brain
  • Analysis of the cerebrospinal fluid (CSF) in the brain and spinal cord for specific proteins
  • Spinal tap to look for abnormalities in antibodies, and look for infections or other conditions with similar symptoms

Treatment

At present, there is no cure for MS.  However, there are several treatments doctors utilize in an effort to manage symptoms, shorten the length of attacks, and modify the progression of symptoms.  Some of them are listed below.

Treatment to Modify Progression

  • Medications to curb the body’s immune system to attempt to stem the body’s attack on the myelin

Treatment for MS Attacks

  • Corticosteroids to reduce nerve inflammation
  • Muscle relaxants
  • Plasma exchange

Treatments for Symptoms

  • Medications (fatigue, depression, and other symptoms)
  • Muscle relaxants
  • Physical therapy
  • Staying cool, sometimes with devises such as a cooling vest (symptoms often worsen when body temperature rises)
  • Alternative medicine (acupuncture, massage, relaxation techniques)
  • Exercise and reducing stress

Treatment will often involve an interdisciplinary approach and may require treatment from a care team including neurologists, physiatrists, urologists, psychiatrists, physical and occupational therapists, and others as needed.

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

References

National Multiple Sclerosis Society, https://www.nationalmssociety.org
Mayo Clinic, https://www.mayoclinic.org
John Hopkins Medicine, https://www.hopkinsmedicine.org
WebMD, https://www.mayoclinic.org

Can You Move Out of the Country and Still Receive Disability Benefits?

The answer depends on what your disability policy says. Many people don’t realize that their policy may limit their ability to receive disability benefits if they move out of the country. If you’ve ever wondered why claims forms ask for your updated address, one of the reasons might be that your policy contains a foreign residency limitation, and your disability insurance company is trying to figure out if they can suspend your benefits.

Foreign residency limitations allow disability insurance companies to stop paying benefits under your policy if you move out of the country. These limitations may be especially relevant if you have dual citizenship, you want to visit family living abroad, or you plan to obtain medical care in another country. A foreign residency limitation may also affect you if your policy allows you to work in another occupation and you have a job opportunity in another country that you want to pursue. For instance, if you are a dentist and can receive disability benefits while working in another occupation, your insurance company may suspend your benefits if the opportunity you pursue is in another country.

Foreign residency limitations benefit disability insurance companies in several ways. By requiring you to remain mostly in the country while receiving benefits, these limitations simplify the payment process and reduce the possibility that insurers will need to communicate with doctors in other countries to manage your claim. They also make it easier for insurance companies to schedule field interviews and conduct surveillance of you to find out if you have done something that could be interpreted as inconsistent with your claim.

While these limitations are not included in every disability insurance policy, it is important to check if your policy—or a policy you are considering purchasing—contains a foreign residency limitation, because it could limit your ability to collect benefits later on.

Foreign residency limitations vary by policy. Here is an example of one foreign residency limitation from a Guardian policy:

This limitation highlights several details you should look for if your disability policy contains a foreign residency limitation, including the length of time you can spend in another country before your insurance company will suspend your benefits, whether you can resume receiving benefits if you return to the country, and when you will have to resume paying premiums if your insurance company suspends your benefits. Another important consideration is the effect a foreign residency limitation will have on your policy’s waiver of premium provision. Under the policy above, premiums will continue to be waived for six months after benefits are suspended. However, your policy may have a different requirement regarding payment of premiums, so it’s important to read your policy carefully.

Here is an example of another foreign residency limitation from a different Guardian policy:

This limitation contains much less detail than the first limitation. For instance, it does not clarify how suspension of benefits will affect waiver of premium. If your disability policy contains a foreign residency limitation that does not discuss waiver of premium, you should look to your policy’s waiver of premium provision to find out when premiums will become due after benefits are suspended. The policy above also defines foreign residency differently than the first policy. At first glance, it may seem that you can continue to receive disability benefits any time you leave the country for twelve months or less. What the policy actually says, though, is that the insurance company will only pay benefits for twelve months that you are out of the country at any time you are covered by the policy. So, if you have received benefits for twelve months while living in another country—even if those months were spread out over several years—your insurance company will not pay benefits in the future unless you are in the United States or Canada.

As you can see, foreign residency limitations vary among disability policies. If you are thinking about leaving the country, it is important to read your policy carefully first so that you understand how leaving the country may affect your ability to recover benefits.

Chronic Pain and Anxiety Disorders

Chronic pain by itself is often debilitating, and the struggle to obtain a correct diagnosis, effective pain management, and ongoing treatment can be stressful and overwhelming.  As we discussed in a previous post, depression often co-occurs with chronic pain, and can further complicate treatment.  The same is true of anxiety disorders.

Chronic Pain Disorders Associated with the Co-Occurrence of Anxiety

Like depression, anxiety is more likely to co-occur with certain conditions, such as:

It is no secret that physicians and dentists have stressful and demanding careers.  One Cardiff University study showed that of 2,000 British doctors, at various stages of their careers, 60% had experienced mental illness.[1]  Often practitioners ignore or fight through both chronic pain and anxiety and show up to work, to the point of endangering themselves or others before acknowledging their disability or seeking adequate treatment.

While anxiety alone can result in an inability to practice, either indefinitely or in the short-term, it is also quite common in those suffering from chronic pain to experience an anxiety disorder.  Anxiety disorders are also the most common type of psychiatric disorders in the United States, with 19 million adults affected.[2]

Chronic Pain and Anxiety—Worse Together

Facing a long-term or permanent disability can be anxiety provoking for a physician, who must (1) face giving up a career he or she invested so much time and financial resources to establish; (2) seek a correct diagnosis, course of treatment, and adequate pain management; and (3) often struggle with adapting to the loss of a previously enjoyed quality of life.  Conversely, chronic pain is also common in people with anxiety disorders,[3]  with up to 70% of people with certain medical conditions (including hypertension, diabetes, and arthritis) had an anxiety disorder first.[4]

Regardless of whether anxiety or chronic pain came first, individuals suffering from anxiety can experience pain that is particularly intense and hard to treat.[5]  In a 2013 study, 45% of 250 patients who had moderate to severe chronic joint or back pain screened positive for at least one of the common anxiety disorders (generalized anxiety, social anxiety, PTSD, OCD).  Further, those that had an anxiety disorder reported significantly worse pain and health-related quality of life than their counterparts without anxiety.[6]

Symptoms of Anxiety[7]

There are several anxiety disorders and, while the below list is by no means exhaustive, sufferers of anxiety often exhibit the following symptoms:

Generalized Anxiety Disorder

  • Difficulty controlling worry
  • Restlessness, feeling wound-up or on edge, irritability, muscle tension
  • Being easily fatigued and problems with sleep
  • Difficulty concentrating or having their minds go blank

Panic Disorder

  • Sudden and repeated attacks of intense fear
  • Feelings of being out of control during a panic attack
  • Intense worries about when the next attack will happen
  • Avoidance of places where panic attacks have occurred in the past

Social Anxiety Disorder

  • Feeling highly anxious about being around other people (including having a hard time talking to them, blushing, sweating, trembling, or feeling sick to your stomach)
  • Feeling self-conscious in front of others and worried about feeling humiliated, embarrassed or rejected, or fearful of offending others
  • Worrying before an event and/or avoiding places where there are other people
  • Having a hard time making and keeping friends

Post-Traumatic Stress Disorder

  • Flashbacks, bad dreams, difficulty sleeping, frightening thoughts, angry outbursts
  • Avoiding places, events, objects, thoughts, or feelings that are reminders of the traumatic experience and trouble remembering key features of the traumatic event
  • Being easily startled and feeling tense or “on edge”
  • Negative feelings about oneself or the world, and distorted feelings like guilt or blame
  • Loss of interest in enjoyable activities

Obsessive Compulsive Disorder

  • Fear of germs or contamination
  • Unwanted or forbidden thoughts, including aggressive thoughts towards others or self
  • Having things symmetrical or in perfect order; excessive clearing and/or hand washing; ordering and arranging things in a precise way; repeatedly checking on things; compulsive counting

Treatments for Anxiety

Some of the treatments that have been successful in addressing anxiety in those with chronic pain include:

  • Cognitive-behavioral therapy (CBT)
  • Psychodynamic therapy (talk therapy)
  • Support groups
  • Relaxation or meditation training
  • Alternative treatments, such as acupuncture and hypnosis
  • Exercise
  • Medication

Chronic pain sufferers who recognize any of the above-referenced symptoms in themselves should talk to their doctor to address these serious issues.

[1] Michael Brooks, Why doctors’ mental health should be a concern for us all, NewStatesmen, April 11, 2016, http://www.newstatesman.com/politics/health/2016/04/why-doctors-mental-health-should-be-concern-us-all

[2] What are Anxiety Disorders?, Global Medical Education, https://www.gmeded.com/gme-info-graphics/what-are-anxiety-disorders

[3] Chronic Pain, Anxiety and Depression Association of America, April, 2016, https://www.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/chronic-pain

[4] Global Medical Education, Supra.

[5] Celeste Robb-Nicholson, M.D., The pain-anxiety-depression connection, Harvard Health Publications, http://www.health.harvard.edu/healthbeat/the-pain-anxiety-depression-connection

[6] Health Behavior News Service, part of the Center for Advancing Health, Chronic pain sufferers likely to have anxiety, ScienceDaily, May 8, 2013, https://www.sciencedaily.com/releases/2013/05/130508213112.htm

[7] Definitions according to National Institute of Mental Health: https://www.nimh.nih.gov/index.shtml

I used to practice __________ but now I’m _____________?

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 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 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.

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.  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 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 insurers.

Comitz | Beethe Attorney Ed Comitz Posts CE Course on Dentaltown

Ed Comitz’s Continuing Education course “Disability Insurance Roulette: Why is it So Hard to Collect on My Policy” is now available through Dentaltown.  This CE is an electronically delivered, self-instructional program and is designated for 2 hours of CE credit.  In this course, Ed discusses why it is so difficult for dentists to collect disability benefits and how to avoid the most common mistakes made by dentists when filing disability claims.  Ed also covers the key provisions to look for in disability insurance policies and provides an overview of the disability claims process.  Finally, the course discusses how disability insurance claims are investigated and administered, and identifies common strategies used by insurance companies to deny claims.

Information on how to register can be found here

For more information regarding what to look for in a policy, see this podcast interview where Ed Comitz discusses the importance of disability insurance with Dentaltown’s Howard Farran.

Chronic Pain and Depression

Chronic pain is often difficult to diagnose and treat.  Consequently, those who suffer from chronic pain typically must also deal with a significant amount of stress, due to repeated failed treatments, numerous medical appointments, interruption of work and enjoyable activities, and the inability of their friends or family to understand their physical limitations.  This can, in turn, cause or worsen depression.  When depression occurs alongside chronic pain, it can make dealing with and treating the pain even harder.

Chronic Pain Disorders Associated with the Co-Occurrence of Depression

While mental health conditions, including depression, can often be disabling in and of themselves, they are unfortunately also quite common in those suffering from chronic pain.  Depression is more likely to co-occur with certain conditions, such as:

  • Back Pain
  • Neck Pain
  • Joint Pain
  • Arthritis
  • Migraines
  • Fibromyalgia

Studies show that rates of depression are high in residents and medical students (15%-30%) than rates in the general population, and the risk of depression continues throughout a physician’s career.[1]  According to a British study, 60% of dentists reported being anxious, tense, or depressed.

Dentists, doctors, and other medical professionals place extreme amounts of pressure on themselves because the stakes of their professions are so high.  In addition to perfectionism and self-criticism, other predictors of depression in doctors include:  lack of sleep, stressful interactions with patients and staff, dealing with death, constant responsibility, loneliness, and making mistakes.[2]

Often practitioners work through both chronic pain and psychiatric disorders for some time before acknowledging their disability or seeking adequate treatment.  In the case of depression, this can be due in part to the social stigma that surrounds it.  For all of these reasons, depression may go undiagnosed or seem less of an immediate concern to those suffering from chronic pain.  However, if you are experiencing symptoms of depression and chronic pain, studies show that it is important to treat both, because chronic pain can become much more difficulty to treat if the depression is allowed to progress unchecked.

Chronic Pain and Depression—Worse Together

Facing a long-term or permanent disability can trigger depression—this is especially understandable for doctors or dentists who have put years into medical school and establishing their careers, only to become disabled and have to step away from a profession that has become a significant part of their identity. Depression can also precede chronic pain.  For example, several studies have examined the link between depression before the onset of back-pain.[3]

Regardless of which came first, together they are formidable to treat.  Major depression is thought to be four times greater in people with chronic back pain than those in the general population, and studies show that individuals suffering from both chronic back pain and depression experienced a greater degree of impairment than those with either depression or back pain alone.[4]

Treatments for Depression

Focusing solely on pain management can prevent both the patient’s and treating physician’s ability to recognize that a psychiatric disorder is also present.  Yet, even with correct diagnoses, both issues can be difficult to treat together.[5]  For instance, those who suffer from both chronic pain and mental illnesses can have a lower pain threshold as well as increased sensitivity to medication side-effects.[6]  Some treatments that have proved successful in addressing depression in those with chronic pain include:

  • Cognitive-behavioral therapy (CBT)
  • Psychodynamic therapy (talk therapy)
  • Relaxation or meditation training
  • Acupuncture
  • Hypnosis
  • Exercise
  • Medication

Symptoms of Depression

  • Little interest or pleasure in doing things
  • Feeling down, depressed, or hopeless
  • Trouble falling asleep or sleeping too much
  • Feeling tired or having little energy
  • Poor appetite or overeating
  • Trouble concentrating
  • Feeling bad about yourself, or that you are a failure or have let yourself or others down
  • Thoughts that you would be better off dead, or hurting yourself in some way

Chronic pain sufferers who recognize any of the above-referenced symptoms in themselves should talk to their doctor to address these serious issues.

_________________________________________________________________________

[1] Robert P. Bright, MD, Depression and suicide among physicians, Current Psychiatry, April 10, 2011.

[2] Id.

[3] William W. Deardorff, PHD, ABPP, Depression Can Lead to Chronic Back Pain, Spine-health.com, Oct. 15, 2004, http://www.spine-health.com/conditions/depression/depression-can-lead-chronic-back-pain.

[4] William W. Deardorff, PhD, ABPP, Depression and Chronic Back Pain, Spine-health.com, Oct. 15, 2004, http://www.spine-health.com/conditions/depression/depression-and-chronic-back-pain.

[5] Celeste Robb-Nicholson, M.D., The pain-anxiety-depression connection, Harvard Health Publications, http://www.health.harvard.edu/healthbeat/the-pain-anxiety-depression-connection.

[6] Anxiety and Depression Association of America, Chronic Pain,  https://www.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/chronic-pain.

Can Your Disability Insurance Company Dictate The Medical Treatment You Must Receive To Collect Benefits? Part 2

“Regular Care”

If you are a doctor or dentist and you bought your individual disability insurance policy in the 1980s or 1990s, the medical care provision in your policy likely contains some variation of the following language:

Physician’s Care means you are under the regular care and attendance of a physician.”

This type of care provision is probably the least stringent of all the care provisions.  If your policy contains a “regular care” provision, courts have determined that you are under no obligation to minimize or mitigate your disability by undergoing medical treatment.[1]  In other words, you cannot be penalized for refusing to undergo surgery or other procedures—even if the procedure in question is minimally invasive and usually successful.[2]

Let’s look at an actual case involving a “regular care” provision.  In Heller v. Equitable Life Assurance Society, Dr. Stanley Heller was an invasive cardiologist suffering from carpal tunnel syndrome who declined to undergo corrective surgery on his left hand.  Equitable Life refused to pay his disability benefits, insisting that the surgery was routine, low risk, and required by the “regular care” provision of Dr. Heller’s policy.  The U.S. Court of Appeals disagreed, and determined that the “regular care” provision did not grant Equitable Life the right to scrutinize or direct Dr. Heller’s treatment.  To the contrary, the Court held that “regular care” simply meant that Dr. Heller’s health must be monitored by a treatment provider on a regular basis.[3]

Unfortunately, the Heller case didn’t stop insurance companies from looking for other ways to control policyholders’ care and threaten denial of benefits.  For instance, some disability insurance providers argued that provisions requiring policyholders to “cooperate” with their insurer grants them the right to request that a policyholder undergo surgery.  Remarkably, when insurers employ these tactics, they are interpreting the policy language in the broadest manner possible–even though they know that the laws in virtually every state require that insurance policies be construed narrowly against the insurer.

Why would insurance companies make these sorts of claims when it is likely that they would ultimately lose in court?  Because insurance companies also know that even if their position is wrong, most insureds who are disabled and/or prohibited from working under their disability policy cannot handle the strain and burden of protracted litigation.  They know that if they threaten to deny or terminate benefits, many insureds will seriously consider having surgery—if only to avoid the stress and expense of a lawsuit.  Unfortunately, this can lead to insureds submitting to unwanted medical procedures, despite having no legal obligation to do so.

As time went on, and more and more courts began to hold that “regular care” simply meant that the insured must regularly visit his or her doctor, Unum, Great West, Guardian, and other insurers stopped issuing policies containing that language.  Instead, insurers started to insert “appropriate care” standards into policies.  In the next post, we will discuss this heightened standard and how insurers predictably used it as a vehicle to challenge the judgment of policyholders’ doctors, in a renewed effort to dictate their policyholders’ medical care.

[1] Casson v. Nationwide Ins. Co., 455 A.2d 361, 366-77 (Del. Super. 1982)

[2] North American Acc. Ins. Co. v. Henderson, 170 So. 528, 529-30 (Miss. 1937)

[3] Heller v. Equitable Life Assurance Society, 833 F.2d 1253 (7th Cir. 1987)

Can Your Disability Insurance Company Dictate The Medical Treatment You Must Receive To Collect Benefits? Part 1

Imagine that you are a dentist suffering from cervical degenerative disc disease.  You can no longer perform clinical work without experiencing excruciating pain.  You have been going to physical therapy and taking muscle relaxers prescribed by your primary care doctor, and you feel that these conservative treatments are helping.  Like most dentists, you probably have an “own occupation” disability insurance policy.  You are certain that if you file your disability claim, your insurer will approve your claim and pay you the benefits you need to replace your lost income and cover the costs of the medical treatment that has provided you with relief from your pain and improved your quality of life.

You file your claim, submit the forms and paperwork requested by the insurer, and wait for a response.  To your dismay, your insurer informs you that its in-house physician has determined that the treatment prescribed by your doctor was inadequate.  Your insurer then tells you that you should have been receiving steroid injections into your cervical spine, and tells you that if you do not submit to this unwanted, invasive medical procedure, your claim could be denied under the “medical care” provision in your policy.

You were not aware that such a provision existed, but, sure enough, when you review your policy more carefully, you realize that there is a provision requiring you to receive “appropriate medical care” in order to collect disability benefits.  You think that your insurer is going too far by dictating what procedures you should or should not be receiving, but you are afraid that if you don’t comply with their demands, you will lose your disability benefits, which you desperately need.

This is precisely the sort of scenario presented to Richard Van Gemert, an oral surgeon who lost the vision in his left eye due to a cataract and chronic inflammation.  Dr. Van Gemert’s disability insurance policies required that he receive care by a physician which is “appropriate for the condition causing the disability.”  After years of resisting pressure from his insurers to undergo surgery, Dr. Van Gemert finally capitulated.  Once Dr. Van Gemert received the surgery, you might expect that his insurer would pay his claim without further complaint.  Instead, Dr. Van Gemert’s insurer promptly sued him to recover the years of benefits it had paid to him since it first asserted that he was required to undergo the surgery.[1]

Unfortunately, “appropriate care” provisions, like the provision in Dr. Van Gemert’s policy, are becoming more and more common.  The language in such provisions has also evolved over time, and not for the better.  In the 1980s and 1990s, the simple “regular care” standard was commonplace.  In the late 1990s and into the 2000s, insurers began using the more restrictive “appropriate care” standard.  And, if you were to purchase a policy today, you would find that many contain a very stringent “most appropriate care” standard.

These increasingly onerous standards have been carefully crafted to provide insurers with more leverage to dictate policyholders’ medical care. However, there are several reasons why your insurance company should not be the one making your medical decisions.  To begin, if you undergo a surgical procedure, it is you—and not the insurance company—who is bearing both the physical risk and the financial cost of the procedure.  Perhaps you have co-morbid conditions that would make an otherwise safe and routine surgical procedure extremely risky.  Perhaps there are multiple treatment options that are reasonable under the circumstances.  Perhaps you believe conservative treatment provides better relief for your condition than surgery would.  These are decisions that you have a right to make about your own body, regardless of what your insurer may be telling you.

In the remaining posts in this series, we will be looking at the different types of care provisions in more detail, and how far insurance companies can go in dictating your care in exchange for the payment of your disability benefits.  We will also provide you with useful information that you can use when choosing a policy or reviewing the policy you have in place. In the next post we will be discussing the “regular care” standard found in most policies issued in the 1980s and early 1990s.

[1] See Provident Life and Accident Insurance Co. v. Van Gemert, 262 F.Supp.2d 1047 (2003)

Unum Study Shows an Increase in Musculoskeletal Disability Claims Over the Past Decade

As we have discussed in previous posts, musculoskeletal disorders are very common among dentists due to the repetitive movements and awkward static positions required to perform dental procedures. Unum, one of the largest private disability insurers in the United States, recently released statistics showing an increase in the filing of musculoskeletal disability claims over the past 10 years.

According to Unum’s internal statistics, long term disability claims related to musculoskeletal issues have risen approximately 33% over the past ten years, and long term disability claims related to joint disorders have risen approximately 22%.  In that same period of time, short term disability claims for musculoskeletal issues have increased by 14%, and short term disability claims for joint disorders have risen 26%.

This trend may lead to Unum directing a greater degree of attention towards musculoskeletal claims as the volume of these claims continues to increase.  Musculoskeletal claims are often targeted by insurance companies for denial or termination because they are easy to undercut—primarily due to the limitations of medical testing in this area.  For instance, it can be difficult to definitively link a patient’s particular subjective symptoms to specific results on an MRI, and other tests, such as EMGs, are not always reliable indicators of the symptoms that a patient is actually experiencing.  Insurers also typically conduct surveillance on individuals with neck and back problems in an effort to collect footage they can use to deny or terminate the claim.  While such footage is usually taken out of context, it can be very difficult to convince the insurance company (or a jury) to reverse a claim denial once the insurer has obtained photos or videos of activities that appear inconsistent with the insured’s disability.

As we have noted in a previous post, Unum no longer sells individual disability insurance policies, so its disability insurance related income is now limited to the premiums being collected on existing policies.  Because benefit denials and termination are the primary ways insurers like Unum can continue to profit from a closed block of business, and musculoskeletal claims are on the rise, Unum may begin subjecting this type of claim to even higher scrutiny.

References:

http://www.businesswire.com/news/home/20160505006009/en/Aging-obesity-tip-scales-10-year-review-Unum

 

Orthopedic Issues Series: Degenerative Disc Disease – Part 2

In Part 1 of this post, we discussed the anatomy of the spine and some of the causes of Degenerative Disc Disease (DDD).   In Part 2 of this post, we will be discussing some of the symptoms of DDD, and some of the methods used to treat DDD.

Symptoms

Not all people with intervertebral disc degeneration experience pain or other symptoms.  This is due to the fact that the degeneration of the discs, by itself, does not bring on the symptoms described in the first paragraph above.  However, as disc degeneration becomes more severe, it can lead to other conditions that bring on the symptoms people normally associate with DDD (e.g., pain, numbness and tingling, weakness, etc.).  Some of the conditions commonly associated with DDD are:

  • Spinal osteoarthritis: Sometimes referred to as spondylosis, this condition occurs when the breakdown of the cartilage and intervertebral discs leads to increased contact and irritation of the vertebrae.  It may also lead to the formation of osteophytes (abnormal bone growths) on the vertebrae that can also put pressure on nerves and contribute to the pain and nerve-related issues described above.
  • Spinal stenosis:  This condition can occur when an individual develops spondylosis. The inflammation associated with spinal osteoarthritis may cause a narrowing of the spinal canal (the hollow space in the middle of the vertebrae through which the spinal cord travels) and put pressure on the spinal cord.  This pressure on the spinal cord can cause numbness, weakness, cramping, or general pain in the arms and legs.  In some cases it can also cause bowel and bladder dysfunction.
  • Foraminal stenosis:  This condition is the result of reduced space between the vertebrae, often brought on by the degeneration of the intervertebral discs.  The reduced space may lead to increased pressure on nerve roots emerging from the spinal cord, resulting in localized pain as well as numbness, tingling, and weakness in the extremities.

Treatment:

Because DDD can cause such a broad range of symptoms and subsequent conditions, the treatment options vary widely.  Depending on the circumstances, treatment can range from conservative options, such as physical therapy and anti-inflammatory medications, to surgical intervention, in the form of a discectomy, laminectomy, laminoplasty, or spinal fusion.

If you are experiencing any of these symptoms, the best course of action is to consult a physician.

For more information on how disability insurers evaluate claims based on Degenerative Disc Disease, see:

A Stiff Upper Lip Can Lead to Getting Stiffed by Your Insurer

Disability Insurance: Who Gets Denied?

Myelopathy: Part 1

Myelopathy: Part 2

Orthopedic Issues Series: Degenerative Disc Disease – Part 1

This post is the first in a series we will be doing on common orthopedic issues.  In Part 1 of this post, we will discuss the anatomy of the spine and some of the causes of Degenerative Disc Disease (DDD), a common yet misunderstood spinal condition that affects a large portion of the population.   In Part 2 of this post, we will go over some of the symptoms of DDD and some of the methods for treating DDD.

Anatomy

There are thirty-three vertebrae in the vertebral column of the human spine, twenty-four of which articulate and move.  Between each of the vertebrae in the three articulating sections of the spine – the cervical, thoracic, and lumbar spine – there is an intervertebral disc.  Each disc, composed of soft jelly-like center (nucleus pulposus) surrounded by a capsule of connective tissue (annulus fibrosis), provides shock absorption and flexibility within the spine.  There is very little blood flow to this region of the body, and if discs are damaged or deteriorate they cannot regrow or heal themselves.

Causes

Degenerative Disc Disease (DDD) is the breakdown in the size and cushioning of the intervertebral discs, which can lead to chronic pain, weakness, numbness and tingling in extremities, and reduced flexibility in the spine. The name of the condition is actually somewhat of a misnomer – it is not actually a “disease”, but rather a condition that is characterized by the degeneration of the intervertebral discs over time. Because of this, the condition can be confusing to understand.

Reduction in the size and cushioning of your discs is part of the normal process of aging, and magnetic resonance imaging (MRI) studies have shown that almost everyone over the age of 60 has degeneration of their intervertebral discs to some degree.[1]  Not all people with disc degeneration have back pain or other symptoms – in fact, individuals with relatively mild disc degeneration may experience no symptoms whatsoever.

However, age is not the only factor in DDD.  Deterioration of the intervertebral discs can be accelerated and exacerbated by other factors.  The culprit in many severe cases of DDD is stress-related damage in the form of repetitive use, trauma, injury, poor posture, poor movement, and obesity.  Among these, one of the most common factors is repetitive use.

Medical professionals are particularly susceptible to developing DDD due to the static postures that some specialties require in clinical practice, most notably dentists.  For example, the repetitive, static posture of a dentist performing clinical procedures creates compressive forces on the cervical discs due to neck flexion and compressive forces on the lumbar discs due to axial loading (the weight of the body compressing the spine vertically).  When these compressive forces are applied for year after year on a daily basis, the result can be an accelerated deterioration of the intervertebral discs.

For more information on how disability insurers evaluate claims based on Degenerative Disc Disease, see:

A Stiff Upper Lip Can Lead to Getting Stiffed by Your Insurer

Disability Insurance: Who Gets Denied?

Myelopathy: Part 1

Myelopathy: Part 2

[1] http://www.arthritis.org/about-arthritis/types/degenerative-disc-disease/

Posture and Your Practice

Good posture is important for everyone, but especially for dentists, who spend a fair amount of time in static positions, making repetitive movements, or bending or twisting in ways that aren’t necessarily natural for human bodies. Today, we’re going to give you some tips on how to improve your posture and positioning in your everyday life as well as your practice, so that you may potentially avoid or delay future disabling pain.

General Posture

  • Keep your body in alignment.
    • While standing, this means distributing your weight evenly on both feet, and making sure that you keep your weight from shifting either forward on the balls of your feet or backward on your heels.
    • When seated, sit up straight and keep your ears, shoulders, and hips in a straight line. A good trick is to picture a balloon attached to the top of your head, pulling you upward.
  • Move around a bit.
    • When your muscles get tired, it’s much easier to slouch or fall into a position that might be comfortable now, but could strain parts of your body you don’t want strained. It’s important to walk around after every half-hour or so of sitting to stretch and refresh your body.
    • Also, moving around slightly while seated is a good way to refresh your muscles. Instead of making your back tight by forcing a constantly straight position, bend a little bit every now and then to reset your posture, and give yourself a break.
  • When working at a desk, use a chair that has good lumbar support or use a small pillow placed between your back and the chair.
    • The spine naturally curves in an “S” shape, so it is important to support your lower back. Ergonomically designed chairs can do this. Using a small pillow for your lower back can also help support your spine.
    • It is also important to sit back in your chair and not on the edge of the seat. A chair is able to provide a solid foundation for your seat only if you use all of the area.
  • Make sure your desk chair is properly aligned to your workspace.
    • Keep your feet flat on the floor and have your hips slightly higher than your knees when sitting at a desk. This will keep you from adding strain to your hip flexor muscles, which play a role in lower back stability.

In the Dental Chair

  • Keep your patient at waist level.
    • This enables you to maintain your proper posture and work safely within your patient’s mouth. It also helps keep your wrists straight, and elbows at 90 degrees, which puts less strain on your arms, shoulders and back.
    • To test it out, hold a 5–pound weight away from your body at waist–height and slowly move it in until your elbows are at 90 degrees. Notice how the weight is much more comfortable to hold when it is closer to your body.
  • Have your tools easily available.
    • Keep everything you may need within a short reach and in front of you so you don’t do any unnecessary twisting, bending or turning.
  • Have better designed tools.
    • You can get lighter tools and angled hand-pieces that allow you to better reach difficult places in your patient’s mouth. It would also be helpful to replace old hoses with ones that are designed to be lighter and straight, so you don’t have to fight the tension of a coil.
    • Gloves are also important: using ambidextrous gloves forces your thumb into an unnatural position and constrains your fingers into one plane, which isn’t anatomically correct. Look into purchasing gloves specifically for your left and right hands to avoid this strain.

While all of these tips can be helpful in preventing future pain, none of them are a cure-all for potential disabilities, and they may not “fix” pain that has already begun. It is essential to have a dialogue with your doctor about any issues that you may be having. It may also be useful to talk to a disability insurance lawyer if you think that your current or future pain may not allow you to continue practicing. We hope that these tips were helpful; let us know in the comments what worked for you!

Carpal Tunnel Syndrome and You: The Issue, and 10 Things You Can Do to Prevent It

Carpal Tunnel Syndrome consists of pain, weakness, numbness, or tingling in the fingers or hand caused by pressure on the median nerve in your wrist. The median nerve controls the feeling and movement in the thumb and all of the fingers except the pinky. For a dentist, this syndrome can be quite debilitating, as this profession requires the full use of both hands in order to examine and perform surgery on patients. Today, we’re going to take a closer look at the symptoms and causes of Carpal Tunnel Syndrome, as well as 10 steps you can take to prevent it from happening.

Symptoms and Causes

While there are multiple symptoms of Carpal Tunnel Syndrome, there are a few that are rather noteworthy:

  • Sleep interruption from numb hands and tingling fingers: you may think that the numbness and tingling is simply due to sleeping on your hand in an awkward position, but there may be more to it than that.
  • Loss of fine motor skills/weakness in hands.
  • Pain radiating up the arm: it may just radiate up the forearm, or it could potentially also make your shoulder and neck ache.
  • Hand pain or wrist pain: this is perhaps the most straightforward symptom of the syndrome.

There seems to be no one cause of Carpal Tunnel Syndrome, but there are several risk factors, including:

  • Anatomic factors: wrist fractures or dislocations can lead to extra pressure on the median nerve.
  • Sex: the syndrome is more common in women.
  • Inflammatory conditions: illnesses such as rheumatoid arthritis.
  • Workplace: working with vibrating tools, holding static positions for a long time, repetitive motions with the wrist. These workplace factors put dentists at a higher risk for contracting Carpal Tunnel Syndrome than the general population.

Continue reading “Carpal Tunnel Syndrome and You: The Issue, and 10 Things You Can Do to Prevent It”

The Injured Physician: Is Your Work Ethic Hurting You and Your Patients?

AzMedicine - cover Winter 2013

Comitz | Beethe disability insurance attorneys Edward O. Comitz and Patrick T. Stanley recently had their article “The Injured Physician:  Is Your Work Ethic Hurting You and Your Patients?” published in the Winter 2013 edition of AzMedicine, the quarterly publication of the Arizona Medical Association.

In the article, Mr. Comitz and Mr. Stanley review some of the unintended consequences, both professional and personal, of a physician continuing to work through adversity, and the potential impact on his or her disability insurance coverage.  For example, a physician who has modified his practice or work schedule in an effort to accommodate a disability may effectively change his occupational definition as it is defined in his “own occupation” disability insurance policy, making it difficult, if not impossible, to collect benefits when they are most needed.

The article also analyzes some of the pitfalls of “residual disability” or “partial disability” riders, such as the manner in which the insurer will determine the amount of benefits paid and differences in how long the insurance company is required to pay benefits.

The Arizona Medical Association periodically updates its website with recent editions of AzMedicine, or you may contact our office to obtain a copy of the full article and/or to speak with a disability insurance attorney.