Out of Contract Demands:
When You Can Tell Your Disability Insurer “No”

Every disability insurance policy is a contract. With this contract come certain rights and obligations on the part of the disability insurance company and on the part of the policyholder. The insurer promises to pay you disability benefits and you promise to fulfill certain conditions. One of the most important things to remember about this contractual relationship is that if it’s not in your policy, you don’t have to do it.

Often, disability insurers will ask a person filing for benefits to do certain things or provide certain information in order to qualify for benefits. What every policyholder needs to realize is that the disability insurer cannot force you to do something that is not outlined in your policy. There are many examples of disability insurance companies’ demands that may not be required under the terms of the policy, such as:

• That you see a certain type of doctor

• That you undergo surgery for your disabling condition

• That you get a particular treatment or therapy

• That you provide your Social Security or workers’ compensation claim file

• That you attend a certain type of examination

• That you complete detailed descriptions of your daily activities

• That you allow a private investigator into your home

The bottom line is that a policyholder filing for disability insurance benefits should know what their policy requires and what it doesn’t. The best way to be sure an insurer doesn’t get away with making extra-contractual demands is to have a disability insurance attorney review your policy and advocate with the company for your rights.

Obtaining an Arizona Disability License Plate or Arizona Disability Placard

In Arizona, drivers with disabilities may be eligible to receive a license plate with a disability symbol—at no extra fee—or a disability placard allowing them to park in spaces reserved with the International Symbol of Access.

Arizona Motor Vehicle Division form application #96-01014 must be completed and signed by a physician or hospital administrator. In order to receive the disability plate or placard, the applicant must have at least one of several disabling conditions, including the inability to walk 200 feet without rest, inability to walk without assistance, lung disease, or severely limited ability to walk due to an arthritic, neurological or orthopedic condition. Further details are available at the Arizona Motor Vehicle Division’s website.

A disability plate is assigned to one vehicle and remains valid for as long as the medical condition continues. The applicant must be an owner on the title of the vehicle.

A disability placard is assigned to the applicant, for use in any vehicle, and may not be transferred to, or used by, another person.

Great Disability Insurance Cases of the 19th Century: Sawyer v. U.S. Casualty Co.

This post is the first in a series exploring great (i.e. interesting) disability insurance cases of the 19th century. Though disability insurance may seem like a modern invention, it originated as early as 1850 in the United States, and 1845 in the United Kingdom. These early cases are not only entertaining to read, but also offer insights into how the field of law developed. It is sad—though not surprising—to see some of the same insurer tactics being used more than a century later.

Today’s great disability insurance case of the 19th century is one of the earliest disability insurance cases reported in the United States. Sawyer v. United States Casualty Co., 8 Am. Law Reg. (n.s.) 233 (Super Ct. Mass. 1869), decided in 1869, was a victory for the plaintiff (the insured), and the start of an entire body of law—disability insurance law. (An earlier disability insurance case, from 1867, held that an insured suffering a hernia was not disabled since he could wear a truss, and is decidedly too dull to discuss here.).

The insured in Sawyer, George W. Sawyer, was a farmer in Worcester, Massachusetts. He was unloading corn from his wagon when he fell, striking his back into the corner of the wagon. After his injury, he was unable to perform many of his prior farm tasks, being restricted only to light work in the barn which did not require lifting. Nor could he work more than half a day at those few tasks he could accomplish. Sawyer hired a man to perform the work which he was no longer able to perform, and his son helped out on occasion.

Sawyer had the foresight to have purchased a disability insurance policy, which paid ten dollars per week if he was “absolutely and totally [disabled] from the prosecution of his usual employment.” The question was whether his abilities qualified as total disability under the terms of the policy. Sawyer argued that if he was “wholly incapable of doing his ordinary and usual work,” then it did not matter that he was still capable of doing some of his duties. The insurer argued that if Sawyer was still capable of doing some of his farm duties, then he was not totally disabled.

The judge instructed the jury: “The mere fact that a man cannot do a whole day’s work, or that by a day’s work he cannot accomplish so much as before the accident, is not sufficient to entitle him to recover, but he must satisfy you that for a time, by reason of his accident, he is deprived of the power to do to any extent substantially all the kinds of labor which constituted his usual employment.” The judge explained by way of example that if a farmer was left with only the ability to milk his cows but not to perform the other usual farm work, then he would be totally disabled and entitled to recover. But if the farmer was still able to perform all of his usual work, even if he was no longer able to perform extraordinarily difficult labor which he may have sometimes done in the past, then he was not totally disabled under the policy and could not recover.

In modern language, the judge set the standard as whether the insured was unable to perform all of the substantial duties of his occupation, regardless of whether he could still perform some of his duties.

The jury found for the plaintiff (the insured). Thus, George W. Sawyer was entitled to his ten dollars per week for the maximum duration of his policy, which was twenty-six weeks.

Though today’s disability insurance policies, particularly those for physicians, provide for much higher benefits, the battles remain similar. Insurers regularly contest whether an insured is totally disabled within the meaning of the policy, and try to misclassify an insured’s occupational duties so as to claim that the insured is still capable of performing the duties of his occupation.

We will be continuing this series with other interesting 19th century cases, so check back frequently for other great cases in disability insurance history.

Unum Reports Minimal Exposure to European Debt Crisis

Unum, one of the largest providers of disability insurance, has reported that its investment portfolio has no exposure to Greek banks, which are currently in disastrous financial shape. The insurer has taken a conservative approach, investing primarily in corporate bonds, and as a result, Moody’s Investors Service has given Unum a third-place rating.

While other insurers, such as Aflac, have taken heavy losses in their investment portfolios due to the ongoing European debt crisis, Unum is proud to announce that beginning in 2003, the company has placed particular emphasis on investments with predictable returns. As Unum’s senior vice president for investor relations told the Chattanooga Times Free Press, “We make steady, predictable payments, so we want a steady, predictable cash flow.” Unfortunately Unum’s payments to disabled doctors are anything but steady and predictable, as the insurer has a track record of unfairly denying claims.

Read: Unum Sidesteps Crisis

Ninth Circuit Opens Third-Party Insurers to ERISA Liability

On June 22, the Ninth Circuit Court of Appeals ruled for the first time that the Employee Retirement Income Security Act (ERISA) permits beneficiaries to sue third-party insurers. Previously, employees participating in an ERISA (employer-sponsored) disability insurance plan could sue only the plan administrator or the plan itself.

Laura Cyr had received a $85,000 salary before becoming disabled. She subsequently sued her employer for gender discrimination and won a retroactive adjustment of her salary to $155,000. When Reliance Standard—who was the insurer but not the plan administrator—refused to approve a similar increase in her disability benefits, Laura sued to enforce her rights. In Cyr v. Reliance Standard Life Insurance Company, the Circuit Court found that although Reliance Standard was not the plan administrator, appropriate circumstances existed to permit Laura’s lawsuit. Laura Cyr is now authorized to have her day in court to recover her benefits and enforce her rights.

A Case Study in Benefit Denial

We frequently emphasize how important it is to consult with a disability insurance law firm before filing a claim. But what about at the moment when you realize that you’re too sick to work? It is vitally important to consult with an attorney specializing in disability law as soon as possible. A recent case in which the insured was denied benefits illustrates the importance of consulting with an attorney from the very beginning of your illness. There are often clauses in your policy which require up-front strategic planning to preserve your claim. In the below case study in benefit denial, the insured found himself possibly covered by two plans but ultimately unable to collect from either.

Paul McKay was employed beginning in 1999 as an attorney at U.S. Xpress, which provided a long-term disability plan to its employees. Prior to January 1, 2004, this plan was provided by Unum. On that date, U.S. Xpress switched disability insurance providers to Reliance. Insurance coverage was supposed to be uninterrupted with employees retaining continuous disability insurance, and in fact it was. But McKay fell between the cracks due to disparate language in the policies.

During his employment, McKay developed significant cervical spine problems, and he eventually underwent surgery in June 2003. Unfortunately between September through December 2003, his condition continued to worsen. At that point he had severe cervical and lumbar disc disease, was frequently absent, and his medication made mental concentration more difficult. His last day of work at the office was December 19, 2003. He intended to work from home during January 2004, but there was no evidence that he was able to do so. U.S. Xpress continued paying McKay his usual salary until January 16 and then fired him on January 19, 2004.

McKay filed a claim with Unum (the insurer prior to January 1, 2004) for disability benefits, contending that he was disabled under the policy. Unum denied the claim. The court affirmed the denial. The problem for McKay was that his Unum policy contained a clause requiring a 20% loss in monthly earnings as a qualifying condition for disability benefits. Unum successfully argued that through December 31, 2003, McKay had not had any loss of earnings as U.S. Xpress had in fact paid him his full salary into January 2004. McKay argued that he may have received his salary but he was incapable of earning it. The court followed the plain language of the policy and regardless of whether McKay earned his keep in December, found no loss and ruled that he was ineligible for benefits.

Reasonably enough, McKay rationalized that if Unum wouldn’t cover him, then he must be covered by Reliance (who took over on January 1). He filed a claim with Reliance, only to discover that Reliance’s policy had two important but often-overlooked requirements: To be eligible for insurance without the usual 60-day waiting period (which would have started coverage on March 1), McKay had to be “actively at work” as of January 1 and his disability had to begin on or after January 1. Reliance denied the claim, asserting that McKay wasn’t “actively at work” because he was not working full-time (at least 33 hours per week) as of January 1. Recall that McKay had attempted to establish his eligibility under Unum by arguing that he had suffered a loss in earnings in December because after December 19 he wasn’t actually earning—just receiving—his salary. McKay’s statements, which had been made in support of his Unum claim, were outrageously used by Reliance to deny him benefits under Reliance’s plan.

The injustice gets worse. As a second reason for denying the claim, Reliance argued that since McKay had asserted a December disability date to Unum, had left the office after December 19, and had since received Social Security disability benefits based on a December 2003 disability date, McKay’s disability began before January 1. Thus, he was ineligible for benefits under Reliance’s plan. The court agreed with Reliance’s reasoning.

On appeal, the Circuit Court affirmed the lower court’s rulings. The Court noted that “McKay argues that because U.S. Xpress maintained uninterrupted LTD insurance coverage during the time period in which he sustained his disability, he must be covered by one of the two policies. McKay’s argument, while somewhat logical, is incorrect. Whether he is covered by either Unum or Reliance, or both, turns on the terms of each policy.” (emphasis added). And so it ends. Paul McKay, who was always “covered” by long-term disability insurance, turned out to not be covered at all. He receives no benefits from either policy, thanks to a coincidence of timing. Each insurer used his statements to the other to deny coverage, leaving him in a no-win scenario.

What can be done differently? Paul McKay should have immediately consulted a disability insurance attorney as soon as he suspected that he might become too ill to work. The attorney could have examined the policies and the upcoming switch in coverage and worked with Paul to develop a strategy to preserve his claim, such as resigning in December and immediately applying for benefits. This case underscores the importance of coordinated planning with an experienced disability insurance attorney.

What Happens If Your Plan Description Doesn’t Match Your Policy’s Terms?

Many people aren’t used to reading insurance policies. With their legal clauses, insurer-defined terms, and dry content, understanding them can be a challenge for insureds. For these reasons, insurers provide plain English summaries of their disability policies, both for marketing purposes and as a guide to benefits. But what happens if you rely upon the plan description in filing a disability claim only to be told that the actual policy language precludes your claim? Your insurer wouldn’t be alone in exploiting a situation where your plan description doesn’t match your policy’s terms.

In the recent case of Weitzenkamp v. Unum Life Insurance Company, the Seventh Circuit Court of Appeals addressed such a discrepancy in a disability insurance policy and plan description. Susie Weitzenkamp was diagnosed with fibromyalgia, chronic pain, anxiety, and depression—all self-reported symptoms. Her summary plan description listed a twenty-four month restriction on disabilities due to mental illness and substance abuse. What the summary failed to mention, however, was that the policy also had a twenty-four month cap on benefits for disabilities primarily based on self-reported symptoms. Ms. Weitzenkamp suddenly found her benefits abruptly terminated.

On appeal, the Circuit Court noted that a summary plan description is intended to be a “capsule guide [to the plan] in simple language.” The relevant law required that the summary include “the plan’s requirements respecting eligibility for participation and benefits” and “circumstances which may result in disqualification, ineligibility, or denial or loss of benefits.” Because the summary failed to mention this important policy provision denying benefits for self-reported symptoms, it violated federal law. The court prohibited Unum from relying upon the policy provision in denying Ms. Weitzenkamp’s claim, reinstating her past benefits though still leaving her to prove her ongoing eligibility under the merits of the policy.

This case illustrates but a portion of the complexity in disability insurance cases. What can physicians do to protect themselves? It is important to thoroughly understand both your actual policy and the insurer’s marketing literature. Physicians should retain all insurer-provided materials from both before and after the purchase of their policy, and consult with an experienced disability insurance attorney should they need to file a claim.

Even Athletes Need Disability Insurance

Many physicians have long been aware of the need to buy disability insurance to protect their income from a disabling injury, but physicians are not the only group needing high-dollar insurance policies. Everyone is at risk of a disabling injury. According to statistics, one-third of all Americans between ages 35 and 65 will become disabled for more than ninety days. Athletes are no exception to the norm, though we usually don’t think of Tiger Woods or Alex Rodriguez as owning disability insurance. For the wealthiest athletes, who can earn a living off of endorsements or other business ventures, disability insurance is probably unnecessary. But for most, it is an often-overlooked yet vitally important safety net.

Consider the June 2003 motorcycle crash of Jay Williams, a promising 2002 NBA draftee who suddenly found himself with a mangled leg, hundreds of thousands of dollars in medical expenses, and, because of a certain motorcycle-riding clause in his contract, suddenly out of a salary. The Chicago Bulls charitably bought out Williams for $3 million, but eight years later, he remains unable to return to the game.

Professional athletes all too commonly fail to realize that disability insurance protects their income as much as it protects the income of a doctor or attorney. It’s no surprise that a recent article suggested disability insurance as one of the first things a new professional athlete should buy. Some prepare even before they turn pro: Shaquille O’Neal played at Louisiana State University while covered under a $2.7 million dollar policy. In fact, one of the NCAA’s lesser known programs is its group disability insurance through which exceptional student-athletes can purchase protection against disabling injuries or sickness. Each year, about 75 top athletes buy insurance through the NCAA program.

There are more similarities than differences between the NCAA’s disability insurance policy and physicians’ disability insurance policies. The NCAA caps its benefits at a maximum of $5 million for first-round NFL draft picks and men’s basketball players, a figure roughly equivalent to the lifetime earnings of many physicians (though the NCAA pays the entire benefit over a fixed 30-month period). And like physicians’ policies, the key question is what constitutes a disability? Continue reading “Even Athletes Need Disability Insurance”

Department of Justice Publishes
New Regulations on Service Animals

The U.S. Department of Justice has recently posted new regulations on service animals. The Department’s fact sheet summarizes these regulations. Generally, persons with disabilities are permitted to have an accompanying service animal in all businesses and in all facilities where the public is normally allowed to go. Staff may only inquire into whether the dog is required because of a disability, and what work or task the dog performs. They may not ask about the person’s disability or require any documentation.

The regulations also for the first time address the use of miniature horses as service animals. Businesses must modify their policies to permit miniature horses where reasonable, with four factors used to determine if the horses can be accommodated in a facility: (1) whether the miniature horse is housebroken; (2) whether the miniature horse is under the owner’s control; (3) whether the facility can accommodate the miniature horse’s type, size, and weight; and (4) whether the miniature horse’s presence will not compromise legitimate safety requirements necessary for safe operation of the facility.

ADA 2010 Revised Requirements: Service Animals

Delaware Becomes First State to Launch a Voluntary Statewide Registry to Assist Persons with Disabilities During an Emergency

People with disabilities in the State of Delaware are now able to sign up with a voluntary registry to assist emergency responders in meeting their special needs in an emergency.   Although some counties throughout the nation have previously implemented similar registries, Delaware is the first to launch a statewide database.  The Emergency Preparedness Voluntary Registry is linked to a secure database that is tied to the state’s 911 system, and the information in the database is immediately available to 911 dispatchers.  The registry can be used to help first responders locate people within the home who are confined to a bed or unable to move without assistance.  In addition, Delaware citizens can share information on those who are hearing-impaired, blind or visually-impaired, speech-impaired, oxygen-dependent, or have other special conditions such as epilepsy, cardiac problems, Alzheimers, and autism.

Having this information regarding a person’s disabilities available to them before arriving at the scene of an emergency is very valuable to paramedics, firefighters and police.  In addition to being of assistance to first responders, local and state emergency planners will utilize the information to plan for state and local and emergencies to help them better serve the disabled community in the event of snow, floods, fires, tornadoes or acts of terrorism.

Delaware Governor Jack Markell provides further information about the registry in the video below.

To enter information about Delaware residents with disabilities into the registry, visit http://www.de911assist.delaware.gov

The 10 Biggest Legal Mistakes Physicians Make
When Filing a Disability Claim (Mistake #1)

If you are a medical or dental professional and are thinking that you may need to file a claim under your disability policy, you may be wondering “Do I need to hire an attorney to file a disability claim?”

Given the voluminous, complex language of modern policies and the amount of money at stake, failing to consult with a lawyer is one of the biggest mistakes professionals make when filing a disability claim. An experienced disability attorney can explain the significance of key policy terms, and work with you to present the best claim possible while avoiding the pitfalls we have identified in our previous posts on this topic.

Ed Comitz’s article, “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), discusses ten of the most significant mistakes to avoid. The excerpt below explains the importance of consulting with an attorney before filing a long-term disability claim:

MISTAKE NO. 1:  Failing to Consult With a Disability Insurance Lawyer

Physicians who are considering filing a claim for disability insurance benefits are advised to meet with an attorney experienced in the area before submitting a claim for payment.  Disability provisions vary greatly in the language used, and coverage is often circumscribed and restricted by qualifying words and phrases.  Accordingly, each insurance policy must be individually reviewed to determine whether a particular claim is covered and, if so, how that claim is best presented to ensure payment.

Action Step:  Physicians should make a coordinated effort with the assistance of an attorney when interpreting their policy, presenting their claim, and providing subsequent information to their carrier.

Insurers have laid plenty of traps throughout the claims process. They will use private investigators, video surveillance, social media platforms, and similar tactics to harvest information and set up your claim for denial or termination.  To learn more about these tactics and other mistakes to avoid, click here.

Search Our Site


The 10 Biggest Legal Mistakes Physicians Make
When Filing a Disability Claim (Mistake #2)

Any medical or dental professional considering filing a claim or weighing long-term disability insurance policy options should be familiar with two key policy terms: “total disability” and “occupation.”

Misinterpreting the definitions of “total disability” and “occupation” and/or falling prey to other common pitfalls can lead to having your claim denied or your benefits terminated.

Ed Comitz’s article “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), details ten of the most significant mistakes to avoid. The excerpt below explains the importance of understanding these crucial definitions in your policy:

MISTAKE NO. 2:   Misunderstanding the Definitions of “Disability” and “Occupation”

Because there is no such thing as a “standard” disability insurance policy, the definitions of “disability” can significantly vary.  Most physicians purchase “own-occupation” policies, which provide compensation following a disability that prevents the insured from performing the particular duties of his or her occupation.  Thus, the insured may be entitled to benefits even if he or she could in fact perform work of a different nature.  The central issue in many cases is the definition of “total disability,” which could variously mean that the insured cannot perform “all” or “every” duty of his or her occupation, or the “substantial and material duties” of his or her occupation. 

Similarly, the term “occupation” may be specifically defined in the policy (e.g., “invasive cardiologist”) or may refer to the insured’s occupation immediately prior to the time that disability benefits are sought.  In the latter situation, if the physician reduces his or her hours in the months preceding claim filing, the insurer may consider his or her occupation to be part-time rather than full-time.  Similarly, the term “occupation” may be comprised not only of the duties of a physician’s specialty, but also of significant travel time, teaching engagements, or other areas in which the physician spends time or draws revenue.  For example, “occupation” may be defined as “internist/professor/business owner,” in which case the physician may not be “totally disabled” if he or she can still teach or perform management functions.

Action Step:  Physicians should read and fully understand their policy terms before filing a claim for benefits.

Even if you read how these terms are defined in your own policy, you may not realize the significance of the definitions if you do not have a full understanding of the claims process and/or you have never seen any other policies for comparison as a frame of reference. Being familiar with the several variations of “own occupation” policies being sold by insurers can help you determine whether you have a true own occupation policy.

To learn more about some of the tactics insurers use to deny claims and other mistakes to avoid, click here.

Search Our Site


The 10 Biggest Legal Mistakes Physicians Make
When Filing a Disability Claim (Mistake #3)

When you file a claim, at some point you will have phone calls with the insurance company regarding your claim. In fact, many companies are now conducting phone interviews when you first call in to request forms. Oftentimes these conversations will be recorded and incorporated into the insurance company’s claim file, but you likely will not receive a copy of the recording unless your claim is denied and you end up filing a lawsuit challenging the denial. And even if the conversation is not recorded, it likely that, following your call, the analyst will be making a note in the claim file summarizing what was said in the conversation.

Because of this, it’s important that you do the same, to ensure there is a complete and accurate record of your interactions with the insurance company. Keeping records of what was said in these phone calls and evading other common pitfalls can help protect your claim from denial and your benefits from termination.

Ed Comitz’s article “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), details ten of the most significant mistakes to avoid. The excerpt below explains the importance of establishing a paper trail with your insurer:

MISTAKE NO. 3:  Inadequate Documentation

When submitting a claim and speaking with their carrier, it is important that physicians take notes to assist them in remembering what was said in the event that their claim is denied.  They should keep notes of all telephone conversations (including the date and time of the call, and what was said) and identify the person with whom they were speaking.  Every conversation with the carrier should be confirmed in a letter sent by certified mail so that there are no misunderstandings.  The “paper trail” may later be used as evidence to establish unreasonable treatment during the claim administration process.

Action Step:  Starting with their first telephone call to their insurer, physicians should document in detail their conversations and meetings, and confirm everything in writing, sent by certified mail.

While you may have jotted down the occasional note when speaking with your disability insurer, you should now have a greater appreciation for the importance of establishing a record of what your insurer says and how they treat you. Detailed notes of conversations with your insurer can help shield valid claims from wrongful denial and even help prove bad faith treatment.

To learn more about some of the tactics insurers use to deny claims and other mistakes to avoid, click here.

Search Our Site


The 10 Biggest Legal Mistakes Physicians Make
When Filing a Disability Claim (Mistake #4)

As part of your long-term disability insurance claim, your insurer may require you to attend an independent medical examination (IME), ostensibly to assess the validity of your filing. Many physicians, dentists, and other professionals (understandably) feel anxious and concerned about attending an IME set up by their insurer.

Ed Comitz’s article “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), details ten of the most significant mistakes to avoid. The excerpt below notes policy language to watch for and covers several helpful steps to consider before, during, and after your IME:

MISTAKE NO. 4:  Blindly Attending an Independent Medical Exam

After submitting their claim, physicians may be asked to submit to an “independent” medical examination by someone chosen and paid for by their insurer.  They may also be asked to undergo exams by someone other than a physician.  Before submitting to an independent medical exam or any other exam or evaluation, physicians must first ensure that their carrier has a right to conduct the exam per the policy language.  For example, a neuropsychological exam is conducted over several days by a psychologist, not a physician, and insurers often use the subjective findings from such an exam to deny benefits.  If the policy requires submitting only to “medical exams” or exams “conducted by a physician,” there is certainly an argument that a physician need not submit to neuropsychological testing.  Further, physicians may wish to be accompanied by an attorney or other legal or medical representatives who can monitor the independent medical exam.  Other considerations include receiving the examiner’s curriculum vitae in advance; limiting the scope of the exam to ensure that no diagnostic test that is painful, protracted, or intrusive will be performed; having the exam videotaped or audiotaped; and receiving a copy of all notes and materials generated.

Action Step:  Because the “independent” medical exam is a tool used for denying benefits where possible, physicians should work with an attorney to ensure that their rights are protected during this process.

Reviewing your policy’s requirements and preparing to attend an independent medical examination can make the process less stressful and protect valid claims from wrongful denial.

An IME is often just one part of your insurer’s broader investigation of your claim. To learn more about other common pitfalls to avoid, click here.

Search Our Site


The 10 Biggest Legal Mistakes Physicians Make
When Filing a Disability Claim (Mistake #5)

Many disability policies now contain provisions that limit coverage for mental conditions. However, each policy also contains specific definition of the types of conditions that are limited and/or excluded, and these definitions can vary greatly from policy to policy.

Ed Comitz’s article “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), details ten of the most significant mistakes to avoid. The excerpt below explains why you should read your policy carefully, to ensure that limitation provisions in your policy are correctly applied to your particular situation:

MISTAKE NO. 5:  Believing All Mental Conditions Are Excluded or Subject to Limitations

Most disability insurance contracts differentiate between mental and physical disabilities.  Most recent policies cut off benefits for psychiatric conditions after two or three years.  Insureds often blindly accept their carrier’s decision to deny or limit benefits based on these conditions without considering numerous relevant factors, including whether there are any physical aspects to the mental condition, whether the mental condition has a biological/organic cause, or whether another, covered condition was the legal cause of the disability.  Without exploring these issues in detail, insureds often blindly accept that certain conditions are limited or excluded from coverage when in fact they are not.

Action Step Physicians should understand their policy’s mental conditions limitation and work with counsel on submitting their claim in such a manner as to ensure payment of benefits.

If you have submitted, or are considering submitting a disability claim, based on a mental illness, be sure to carefully review your policy’s language and do not simply assume that all mental conditions are excluded. And if your insurance company relies on one of these limitation provisions to deny your claim or limit your benefit period, you should consult with a disability insurance attorney and assess whether the insurance company’s decision is proper under the terms of your policy.

To learn more about the tactics insurers use to deny claims and other mistakes to avoid, click here.

Search Our Site