What is an Independent Medical Exam?

An independent medical exam (“IME”) is an exam conducted by a doctor to verify whether you are truly disabled under your disability insurance policy’s terms.  These IMEs are rarely “independent”, and the doctors conducting them are almost always selected and paid by the insurers. In this post, we will explain what you can expect during an IME, and how you can protect yourself during the IME process.

What Can I Expect During an IME?

The IME doctor will likely begin by conducting an interview to learn about your medical history, the nature of your job, your symptoms, your treatment to date, and your daily activities.  During the interview, the doctor will be looking for signs that you are not telling the truth or that you are exaggerating your symptoms and limitations.  The doctor will pay attention to your demeanor, body language, and general appearance in order to assess your credibility.  The doctor will also compare your reported symptoms and limitations to your medical records, claim forms, and daily activities in an attempt to find inconsistencies.

Typically, the IME will largely consist of a physical examination, and the doctor may also require objective testing, such as x-rays, MRIs, or EMGs.  The doctor will often begin by conducting a general checkup, taking height/weight measurements, listening to your heart and lungs, testing your blood pressure, etc.  The doctor may then perform tests that focus on your disability and require you to provide subjective indications of pain and discomfort. He or she may ask you to bend, lift, or perform simple physical movements, depending on the nature and location of your condition.  Again, the doctor will be looking for inconsistencies or any signs that you might be exaggerating your symptoms.

After the IME, the doctor will complete a report that summarizes the findings of the exam.  The doctor will opine as to the extent of your disability, your ability to return to work, and recommended treatment or further testing.

How Can I Protect Myself in the IME Process?

As explained above, IMEs can be used as a tool for the insurance companies to deny or terminate disability benefits. Fortunately, there are ways you can protect yourself and ensure that you are treated fairly before, during, and after the IME.

Before the IME:

  • Review your policy. Most insurance policies do have a provision that allows the company to require you to submit to a physical exam.  However, these provisions are sometimes unclear as to the exact type examinations that are allowed.  Review the terms of your policy to make sure that your insurer can require you to undergo an IME.
  • Complete intake forms in advance. Your doctor will most likely ask you to complete intake forms, including questionnaires that outline your symptoms and medical history.  If you are nervous or hurried, you may forget to include important information.  Filling out the forms in advance allows you to answer each question carefully and accurately.

During the IME:

  • Bring a friend. If possible, bring a friend or family member to the IME. Not only can your friend provide moral support, but they will also serve as a witness to the exam.
  • Take notes. If possible, take notes during the IME to remember what testing was performed or what types of questions were asked. When you leave, write down your impressions and any issues you think you need to follow-up on.
  • Be cooperative and open.  Be patient and polite with the doctor.  Answer questions in a straight-forward and truthful manner, and if you do not understand something, let the doctor know. While you should be cooperative, this does not mean you need to do anything that causes you pain or injury. You know your body and limitations best, so if something the doctor asks you to do will cause you pain, let him or her know.
  • Discuss your symptoms fully and honestly. Do not minimize your symptoms and do not be afraid to complain.  It is important that your pain levels and other symptoms are documented as accurately and thoroughly as possible.
  • Connect your symptoms to your job duties. Make sure you discuss how all of your conditions impact your ability to practice safely and effectively. Give specific examples of how the conditions interfere with your practice (e.g., you cannot sit or stand for long periods without pain; you cannot manipulate dental instruments due to numbness in the fingers, etc.).

After the IME:

  • Get a copy of the report. After the exam, contact your insurer to ask for a copy of the IME report.  Review the report and compare it to your notes and recollection of the IME.  If anything needs to be clarified or there are any inconsistencies, contact your attorney and/or disability insurer as soon as possible.

If you have been scheduled for an IME, you may want to get an experienced disability insurance attorney involved.  An attorney can protect your rights during the IME process by finding out what the disability policy requires, limiting the test to certain parameters, studying the examiner’s credentials, recording the exam, accompanying you to the exam, and reviewing the final report for accuracy.

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Can You File a Disability Claim for Vision Problems?

It’s no secret that dentistry is hard work, requiring concentration, precision, visual acuity, depth perception, and quick reaction time if there is an emergency situation [1].  In prior posts, we have discussed how, as a result of these demands of the profession, musculoskeletal conditions are all too common in dentists, and often lead to dentists needing to file disability insurance claims. Similarly, a dentist who undergoes changes to his or her vision, whether via injury or disease, faces the very real possibility that he or she may need to step away from practicing dentistry early. In fact, one study showed that sight disorders were the second most common reason dentists asked for help (34.7% in females, 32% in males)[2], and the same study showed that sight disorders were recorded in 45.7% of the female dentists participating in the study and 48.5% of the male dentists, with eye injuries being the most common reported reason for seeking help.

Some eyesight injuries/impairments experienced by dentists may occur on the job, through physical hazards (radiation, artificial light) or chemical hazards (dental materials, including amalgam and dental cement particles, equipment, disinfectant, etc.).[3] Diseases of the eye are also not uncommon as one ages, and older dentists may find it increasingly challenging to effectively practice when faced with an eye disease, especially during procedures that require a significant degree of hand-eye coordination (e.g. root canals, crown procedures, etc.).

Some of the most common eye conditions in adults include age-related macular degeneration, cataracts, central retinal vein occlusion, retinopathy (due to diabetes), macular edema, glaucoma, and retinal tears and detachments. Many of these conditions can cause symptoms that can limit a dentist’s ability to practice safely and effectively (e.g. blurred vision, floaters, halos around lights, double vision, difficultly seeing in low or bright light, etc.), and over times some can even result in partial or total blindness. In addition, there are several lesser-known genetic eye conditions that can have equally devastating effects on a dentist’s ability to safely practice, including retinitis pigmentosa, choroideremia, Best disease, and cone rod dystrophy, among others.

Whether sight impairment and/or vision loss occurs through a common or rare disorder, vision problems are often slowly degenerative and progressive. In some instances, there may be ways to acceptably compensate for the vision impairment, whereas in other instances the impairment can be severe enough that it is obviously disabling. However, like other slowly progressive conditions, there is often a significant gray area between these two extremes that can be difficult to navigate if you do not have an understanding of how the disability claims process works. Dentists facing a progressive eye condition must carefully (and constantly) balance the need to keep their practice running, support their families, and continue the job they love against their duty to keep their patients safe and the risks of board complaints and/or malpractice lawsuits.

As a result, we’ve often seen dentists try to continue working even after a serious diagnosis by reducing their hours and/or the types of procedures they perform; however, doing so can hurt your chances to collect under a future disability claim, as this can undercut the severity of a claim and re-define the job duties, potentially making it much harder to establish total disability under the terms of your policy. Because of this, if you are a dentist with an eye condition that could potentially be disabling in the future, it is a good idea to have someone who is familiar with the claims process (like an experienced disability insurance attorney) evaluate your situation and start preparing a transition plan so that, if things progress to the point where you do have to file a claim, you are prepared.

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 physician do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

 

References:

Mayo Clinic, www.mayoclinic.org
National Eye Institute, https://nei.nih.gov
U.S. National Library of Medicine, https://ghr.nlm.nih.gov
Retina International, http://www.retina-international.org
American Academy of Ophthalmology, https://www.aao.org
American Society of Retina Specialists, https://www.asrs.org

[1] Dhanya Muralidharan, Nusrath Fareed, & M. Shanthi, Musculoskeletal Disorders among Dental Practitioners: Does It Affect Practice?, Epidemiology Research International, Vol. 2013, Article ID 716897 (2013)

[2] Marin Vodanovic, Slavica Sovic, & Ivan Galic, Occupational Health Problems and Dentists in Croatia, Acta Stomatol Croat., 2016 Dec; 50(4): 310-320

[3] Id.

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“Do You Have a True ‘Own Occupation’ Policy?”

As a dentist, you probably have purchased at least one disability insurance policy, and you probably sought out “own occupation” coverage. However, in our experience, many dentists do not understand what their policy actually says or realize that there are several variations of “own occupation” policies. Additionally, many of the newer disability policies being sold to dentists have particular requirements and “rules” that must be followed in order to qualify for benefits.

Our latest article with Dentaltown Magazine discusses some of these pitfalls and explains why it is important to know what your policy says before filing a claim. Read the full article at Dentaltown today.

https://www.dentaltown.com/magazine/article/7481/do-you-have-a-true-own-occupation-policy



Doctor Money Matters Podcast
Q & A with Ed Comitz, Esq.
What Every Physician Should Know About Disability Claims

Ed Comitz recently sat down with Dr. Tarang Patel, host of the popular Doctor Money Matters Podcast, to talk through some of the most common questions physicians have about filing disability claims, such as:

  • What should a physician look for in a disability policy?
  • How hard it is for a physician to collect disability benefits?
  • Do I need a lawyer to file a disability claim?
  • What is the disability claims process like?
  • If I have an “own occupation” policy, can I work in a different occupation and still collect disability benefits?
  • What are the most common pitfalls that lead to physician’s claims being denied?

Click here to listen to Part 1 of the Podcast: https://www.doctormoneymatters.com/episode44/ and here to listen to Part 2: https://www.doctormoneymatters.com/episode45/.

Episodes can also be accessed on www.drmoneymatters.com, and via iTunes, Google Play, Stitcher and other podcast platforms along with Facebook and YouTube.

 

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What is the Effective Date of My Disability Policy?

The “effective date” of a policy is the day your policy becomes enforceable. While this may seem like a simple concept, it is not always as straightforward as you might think. Understanding the date your policy became effective may require you to read several different provisions together. Additionally, if you apply for benefit increases at a later date to increase your policy’s monthly benefit, this can further complicate matters because, depending on the terms of your policy, you can end up with multiple effective dates for the same policy (corresponding to each benefit increase to the base amount).

Here is an example of a provision defining the effective date of a policy (taken from an actual policy):

————————————————————————————————————————————

EFFECTIVE – Coverage is Effective when this Policy is issued and delivered to You provided the first full premium is then paid and all answers on the application are true and complete as if made at the time of delivery.

Coverage is Effective on the Issue Date if a premium was paid at the time of the application; the Conditional Advance Premium Receipt was given at that time; and this Policy was issued at standard rates exactly as applied for.

Additional coverages are Effective on the Monthly Anniversary on or after the date We issue the new Policy Specifications containing the coverage, subject to payment at the initial premium. If the initial premium is not paid when due, the coverage will be treated as never having been Effective and new Policy specifications will be issued showing this fact.

————————————————————————————————————————————

Under this provision, there are three possible effective dates. First, the policy’s coverage will be effective when the policy is issued and delivered, as long as the first premium was paid and the application was accurate when it was submitted.

However, the provision alternatively states that the policy can be effective on the “Issue Date.” In this scenario, the policy will be effective on the “Issue Date” if: (1) a premium was paid at the time the application was completed and submitted; (2) a receipt for this payment was given to the policyholder at that time; and (3) the rates in the policy are exactly what were applied for. But what is the “Issue Date?” This is also separately defined in the policy:

————————————————————————————————————————————

ISSUE DATE – The date the Policy Specifications are printed. Subsequent Policy Specifications carry their own Issue Dates.

————————————————————————————————————————————

Finally, if the policyholder purchases additional benefits after the original policy has been issued, there is a different effective date for this new coverage (i.e. additional coverages are effective on the “Monthly Anniversary” on or after the new policy specifications are issued, as long as the first premium is paid). This requires the policyholder to understand what “Monthly Anniversary” (another separately defined term) means:

————————————————————————————————————————————

MONTHLY ANNIVERSARY – [This date is] computed from the Policy Date shown in the Policy Specifications…. The Monthly Anniversary is the same date in each succeeding month as the Policy Date.

————————————————————————————————————————————

So, as you can see, under some policies, determining when your coverage becomes effective (and/or whether benefit increases apply to your claim) can be particularly complicated and depend on the particular facts at play. Disability insurance policies—particularly newer disability policies—are complex documents, and insurers often take advantage of this complexity when denying claims. If you are having difficulty understanding your policy’s provisions, an experienced disability insurance attorney can help you interpret confusing policy language and apply it to your particular situation.

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Disability Insurer Profiles: Unum

Unum, originally called Union Mutual, was founded in 1848. Over the years, Unum has merged with additional companies such as Colonial Life and Provident (which had acquired Paul Revere) to form one of the largest insurance companies in America.[1] In 2017, Unum’s total revenue reached $11.3 billion, with total assets of $64 billion.[2]

In 2004, Unum was the subject of a multistate market conduct examination which identified the following inappropriate claims handling practices: (1) excessive reliance on in-house medical staff; (2) unfair evaluation of attending medical examiner notes; (3) failure to evaluate the totality of the claimant’s medical condition; and (4) an inappropriate burden placed on the claimants to justify eligibility for benefits. Following the 2004 investigation, Unum was required to reform its claims practices and pay a fine of $15 million. Unum was also required to reassess certain denied claims stretching over a seven year period. It is estimated that compliance with the settlement cost Unum around $120 million.[3]

If you are a dentist or physician with a Unum policy and are thinking about filing a disability claim, you should be prepared for an in-depth evaluation of your occupational duties. When a disability claim is filed by a professional, the amount of money at stake is significant. One way for the companies to save money is to deny the claim. Another is to maintain that the claim is not a “total disability” claim, but rather a “residual disability” claim, so they only have to pay a fraction of the full monthly benefit amount.

Whether a claim is a “total” or “residual” disability claim often come down to how the duties of your pre-disability occupation are defined in the context of your claim. Then, the insurer assesses whether it can argue that you can still perform any of those duties, taking into account what your medical records report regarding your limitations and any post-disability job or volunteer activities you may be engaging in. Even if your policy allows you to work in another occupation and still collect benefits, the insurance company may argue that your new job has overlapping job duties with your prior occupation, and therefore you are only partially disabled.

For example, in Ogborne v. Unum[4], a dentist filed a disability claim with Unum after suffering a ligament injury to his right index finger. His doctors told him that his injury would be slow healing, and eventually told him that his injury was permanent. Unum denied his claim, stating that he had given untimely notice of the claim and that the dentist was not “totally disabled” because his particular injury only prevented him from performing “two types of procedures.” Unum also relied on the fact that the dentist had returned to work and was making more money than he had before the injury.

The dentist sued to challenge the denial, and the court determined that Unum was improperly interpreting the definition of “total disability” under the policy, which defined “total disability” as “the inability of the Insured to perform the duties of his regular occupation.” The court observed that “[t]his definition is susceptible to two different, yet reasonable, interpretations: namely, that the insured is totally disabled if he cannot perform either more than one of his pre-injury duties or all such duties.” Then the court determined that the ambiguous language should be construed against Unum, as the drafter of the contract.

Next, the court determined that the dentist had, in fact, produced evidence demonstrating that he was unable to perform several of the duties of dentistry, including root canals, periodontal work, and root scaling. Ultimately, the court ordered Unum to overturn the denial, but it took several years and a favorable decision from a judge to get Unum to pay benefits.[5]

These are just a few examples of things to be aware of if you have a Unum policy or claim with Unum. Unum policies are not all identical, and they are updated frequently. Your policy may or may not include the provisions mentioned above. If you are considering filing a disability claim, you should consult with an experienced disability insurance attorney to learn more about your policy and any potential issues related to your particular claim.

 

[1] https://www.unum.com/about/corporate/history.

[2] https://investors.unum.com/Cache/1001235181.PDF?O=PDF&T=&Y=&D=&FID=1001235181&iid=103324.

[3] https://www.insurancejournal.com/news/national/2004/11/18/47854.htm.

[4] Ogborne v. UNUM Life Ins. Co. of Am., No. 3:04CV7231, 2006 WL 2505905, at *2 (N.D. Ohio Aug. 28, 2006).

[5] It should be noted that this particular case was also decided under Ohio law. As the law regarding how disability policies are interpreted varies from state to state, this case could have come out differently in a different jurisdiction.

 

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Disability Insurer Profiles: Standard

Standard Insurance Company (also branded as “The Standard”) is one of the largest disability insurance companies in operation, with over $4.3 billion collected annually from premiums.[1]

If you have a Standard policy, you will want to pay close attention to how disability is defined under the policy, as Standard policies can contain provisions that shift from “own occupation” coverage to “any occupation” coverage after a certain period of time.[2] Because of this, Standard will sometimes approve a claim initially, but then reassess and terminate the claim when the more stringent “any occupation” provisions kicks-in later on.

For example, in Pringle v. Standard Insurance Company, Standard initially found the claimant to be disabled due to bilateral shoulder pain, bilateral knee pain, and numbness in his legs, feet and toes. Later on, after the “any occupation” definition replaced the “own occupation” definition of disability, Standard terminated the claim (and subsequently denied the claimant’s appeal of the claim termination) even though the claimant’s treating physicians had all opined that he could not work.

In support of its termination decision in Pringle, Standard relied on memos produced by its physician consultants after file reviews of the medical records. Notably, while other companies often only have one doctor conduct a file review of the record when evaluating whether to deny a claim, Standard in this case paid three doctors of various specialties to review the record and author peer review reports. Accordingly, if you have a Standard policy, it is important that you have supportive doctors and accurate and up-to-date medical records that support your claim, because you may have to go up against multiple physician reports if your claim is denied.

Another tool that Standard uses is the peer-to-peer call, where it assigns a doctor to contact your treating physicians to discuss your claim. This can be problematic, because the doctors hired by Standard (and other insurers) are often adept at asking trick questions, and don’t always explain the significance of how key terms like “own occupation” or “total disability” are defined in your particular claim. After the call, the insurance company’s doctor will typically prepare a letter “summarizing” the call in a way that favors the insurance company, in the hopes that your doctor (who is likely very busy) signs off on it without reading it carefully.

In the Pringle case, mentioned above, Standard’s doctor conducted this sort of call and the follow-up letter to the primary care doctor stated, in part, “you indicated the claimant was a ‘muscular guy’ and that, from your perspective, the claimant could function at a sedentary capacity as people in wheelchairs and who have had amputations are capable of working at a sedentary capacity.” According to the case record, the primary care doctor ended up signing off on this statement, even though it is arguably inconsistent with what the primary care doctor stated in his prior records and opinions (raising the question of whether he, in fact, read it before signing and sending it back to Standard). Ultimately, in Pringle, the court reversed the termination and required Standard to pay back benefits, but it took several years of costly litigation in order to get the denial reversed and the benefits reinstated.

These are just a few examples of things to be aware of if you have a Standard policy or claim with Standard. Standard policies are not all identical, and they are updated frequently. Your policy may or may not include the provisions mentioned above. If you are considering filing a disability claim, you should consult with an experienced disability insurance attorney to learn more about your policy and any potential issues related to your particular claim.

[1] https://www.standard.com/sites/default/files/2017annual_statement_sic.pdf.

[2] See, e.g., Pringle v. Standard Ins. Co., No. 3:18-CV-05025-RBL, 2019 WL 912297 (W.D. Wash. Feb. 25, 2019).

 

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The Importance of Reading Your Policy

In previous posts, we have discussed why it is important for professionals to be actively engaged in choosing their disability policies. While agents can provide helpful advice, it is ultimately your financial well-being on the line, and ultimately up to you to review your policy, become familiar with the provisions of the policy, and confirm that you are paying for the coverage that you expected to receive.

The case of Jacobs v. Chadbourne[1] illustrates the importance of reading your policy. In Jacobs v. Chadbourne, Gene Jacobs purchased disability insurance from Unum through the services of an independent broker. Two years later in 1988, Jacobs asked his broker about adding lifetime coverage to his policy, and Unum issued Jacobs a “Lifetime Total Disability Benefit Rider.” This rider stated that Unum would pay benefits if Jacobs’ disability begins before age 65 and continues until age 65. However, Jacobs was reportedly unaware at the time that this rider also stated that his maximum monthly insurance benefit would decrease 10% for each year after age 55 and until age 65.

In 2003, Jacobs called Unum to confirm his benefits in his disability policy. Unum faxed a letter outlining Jacobs’ benefits, which provided the policy’s issue date, the monthly premium, and the maximum monthly benefit. Notably, this letter did not mention the lifetime rider or the 10% reductions described in that rider.

In 2011, Jacobs submitted a claim for total disability benefits based on a date of disability at age 64. Unum accepted his claim and began paying benefits to him, which were subsequently reduced because of the restrictions in the lifetime rider. Jacobs sued Unum and his broker (Chadbourne) for their failure to mention the lifetime rider’s restrictions in the 2003 letter, and argued that he should be entitled to 100% of the benefit amount because he didn’t know about the percentage reductions outlined in the rider.

The Court held that, because Jacobs had the policy and lifetime rider in his possession, he was responsible for knowing the contents of his policy. The Court also found that Unum and Chadbourne had not misrepresented his coverage amounts or otherwise perpetrated fraud or injustice in the 2003 letter.  Even though his broker had failed to explain the lifetime rider’s restrictions when Jacobs first purchased the coverage in 1988, and even though Unum had failed to even mention the lifetime rider when Jacobs asked about the benefits in his policy in 2003, the Court determined that Jacobs should not be rewarded for failing to read his policy.

This case highlights the importance of reading your policy and fully understanding its provisions.  Oftentimes, marketing materials and policy summary sheets only outline the benefits of the policy, and you have to read the fine print to have a full understanding of the limitations of the policy. If you are considering purchasing a policy, you should not accept coverage or pay premiums for a policy until you have thoroughly reviewed and understand what you are paying for.

[1] Jacobs v. Chadbourne, No. 17-12868, 2018 WL 2068648 (11th Cir. May 3, 2018).

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Disability Insurer Profiles: Mutual of Omaha

Mutual of Omaha (also known as United of Omaha Life Insurance) was founded in 1909 and is now one of the largest insurance carriers in the United States, with an operating income of $554.8 million and revenues of $8.7 billion in 2017.[1]

If you have a claim with Mutual of Omaha, you may be asked to produce “objective” evidence of your disability.  Sometimes, this is an express requirement of the policy. In other instances it is simply a question asked on the claim forms (for example, an attending physician statement). Or sometimes it is question asked in a peer-to-peer call from the insurance company’s doctor to your doctor. Regardless of how it comes up, characterizing a claim as being based on purely “subjective” reports (as opposed to being based on “objective” evidence) is a common tactic that Mutual of Omaha (and other insurance companies) use to deny and terminate claims.

For example, in Schatz v. Mutual of Omaha[2], a nurse filed a disability claim due to chronic back pain. Notably, at the time she filed for disability, the nurse was working as a medical review nurse for Mutual of Omaha. Nevertheless, Mutual of Omaha denied her claim and refused to pay her benefits under her policy.

In fact, when the nurse sued Mutual of Omaha to challenge the denial, the fact that she worked for Mutual of Omaha ended up hurting her case, to some extent, because the court assumed that Mutual of Omaha understood her particular job duties. Consequently, the court excused Mutual of Omaha’s failure to conduct a detailed inquiry into the physical demands of her position—an omission that otherwise may have proved significant.

In addition, Mutual of Omaha claimed that the nurse’s medical records were not “consistent” or “conclusive,” pointing to a statement from the nurse’s long-time treating physician stating that his opinion that she should not work was not based on “some new objective finding” but was based on the nurse’s reports that “she couldn’t tolerate the pain, that she couldn’t do it and it wasn’t getting better.”

Similarly, the physician selected to perform an independent medical exam stated that, although the nurse reported “multiple subjective complaints,” the physical exam was “essentially normal.” In light of these statements, the court ultimately held that Mutual of Omaha’s denial of benefit was proper, under an abuse of discretion standard.

These are just a few examples of things to be aware of if you have a Mutual of Omaha policy or claim with Mutual of Omaha. Mutual of Omaha policies are not all identical, and they are updated frequently. Your policy may or may not include the provisions mentioned above. If you are considering filing a disability claim, you should consult with an experienced disability insurance attorney to learn more about your policy and any potential issues related to your particular claim.

 

[1] https://www.mutualofomaha.com/our-story/newsroom/article/mutual-of-omaha-reports-2017-financial-results.

[2] Schatz v. Mut. of Omaha Ins. Co., 220 F.3d 944 (8th Cir. 2000).

 

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Unum Study Shows an Increase in
Musculoskeletal & Joint Disorder Disability Claims
Over the Past 10 Years

As we have discussed in previous posts, musculoskeletal disorders are common among dentists because the profession requires dentists to perform repetitive movements and hold static positions for long periods of time.  Unum, one of the largest private disability insurers in the U.S., recently released the results of a ten-year review of its disability claims, showing that both short and long term disability claims for musculoskeletal issues and joint disorders have increased significantly.

According to Unum’s internal statistics, long term disability claims related to musculoskeletal issues have risen approximately 41% over the past ten years, and long-term disability claims related to joint disorders have risen approximately 24%.  In that same period of time, short term disability claims for musculoskeletal issues have increased by 24%, and short-term disability claims for joint disorders have risen 29%.

Unum no longer sells individual disability insurance policies, so the profitability of this block of business is reliant upon premiums received from existing policyholders (or costs saved by denying/terminating claims).  Musculoskeletal claims made by physicians, dentists, and other professionals in particular are intensely scrutinized, and often targeted for denial or termination, both because of the increasing number of claims and the difficulty claimants often face in trying to prove up their conditions (which often have primarily subjective symptoms that aren’t often verifiable through a medical exam, or via tests like MRIs or EMGs). In musculoskeletal claims insurers may request that physicians and dentists undergo tests such as independent medical examinations (IME) or functional capacity evaluation (FCE), or the insurer may conduct surveillance in order to find manufacture a basis for denying or terminating a legitimate claim.

Given the rising number claims based on these conditions, Unum and other insurers may subject them to even higher scrutiny.  For this reason, physicians, dentists, and other professionals must be aware of the obstacles they can face when filing a claim.

References:

https://www.businesswire.com/news/home/20180503006409/en/Ten-year-review-Unum%E2%80%99s-disability-claims-shows-trends.

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Disability Insurer Profiles: MetLife

Metropolitan Life Insurance Company, or MetLife, is one of the largest insurance providers in the world. Originally founded in 1868, the company now employees almost 50,000 people, services over forty national markets, and reported $22.925 billion in revenue from premiums alone in 2017.[1] MetLife discontinued the sale of individual disability policies in March 2017 and now only sells group policies.[2]

If you have a MetLife policy and are considering filing a claim, it is important to recognize that a disability claim is an ongoing evaluation. Even if your claim is initially approved, the disability company has a right under most disability policies to continuously re-assess whether you remain “totally disabled.” Given the amount of money on the line, MetLife (like other insurance companies) will typically review its claims periodically, to see if there is any basis to terminate benefits. This can be problematic for physicians and dentists who are not anticipating this degree of ongoing scrutiny, and have not taken the time to understand how their policy works.

One common mistake that physicians and dentists make is going back to work in a new job, without understanding how that will impact their claim. For example, in Abena v. MetLife[3], a dentist filed a disability claim due to pain and numbness in his hands and arms. MetLife initially approved his claim, but roughly a year after his disability date, MetLife learned that the dentist has started a new job as the director of the dental clinic at a university.

MetLife investigated the new position, and determined that the job responsibilities of the clinic director at that particular university included providing direct patient care, which MetLife maintained was inconsistent with the dentist’s disability claim. Next, MetLife hired an investigator to conduct surveillance of the dentist over a three day period, and concluded that the dentist was able to engage in a variety of daily activities and tasks without any apparent limitations or problems. Finally, MetLife hired a doctor to review the dentist’s medical records, and the consultant doctor determined that the dentist had no physical impairments that would preclude him from practicing dentistry.

At this point, MetLife terminated the dentist’s claim. The dentist appealed, but MetLife upheld its decision on appeal. The dentist eventually sued MetLife, but did not file the lawsuit until three years after the MetLife’s decision to uphold the termination. Because the dentist waited too long to file the lawsuit, the court dismissed the lawsuit without even considering whether the termination was improper.

These are just a few examples of things to be aware of if you have a MetLife policy or claim with MetLife. MetLife policies are not all identical and they are updated frequently. Your policy may or may not include the provisions mentioned above. If you are considering filing a disability claim, you should consult with an experienced disability insurance attorney to learn more about your policy and any potential issues related to your particular claim. And if your claim has been denied or terminated, you should talk with an attorney as soon as possible, to ensure that you do not forfeit your right to challenge the insurance company’s decision.

[1] https://investor.metlife.com/node/30501/html.

[2] https://www.metlife.com/support-and-manage/current-customers/individual-disability-insurance/.

[3] Abena v. Metro. Life Ins. Co., No. 06-C-495, 2007 WL 1575354, at *1 (E.D. Wis. May 29, 2007), aff’d, 544 F.3d 880 (7th Cir. 2008).



Thoracic Outlet Syndrome

In previous posts, we’ve discussed chronic pain, including how chronic conditions can affect dentists.  Dentists in particular are susceptible to these conditions, as they are constantly required to employ sustained grips on instruments while holding awkward, unnatural positions during dental procedures.  As a result, dentists are prone to developing disorders that cause muscle pain, weakness, and numbness, including thoracic outlet syndrome.  In this post we will examine the symptoms, causes, diagnosis, and treatment of thoracic outlet syndrome.

Overview

Thoracic outlet syndrome (TOS) is a group of disorders that occur when blood vessels or nerves in the space between the collarbone and the first rib (thoracic outlet) are compressed. This can result in pain in the shoulder, neck, and arm, as well as numbness in the fingers.

There are different types of TOS, including:

  • Neurogenic (neurological) thoracic outlet syndrome: This form of TOS is characterized by compression of the brachial plexus (a network of nerves that come from the spinal cord and control muscle movements and sensation in the shoulder, arm, and hand).
  • Vascular thoracic outlet syndrome: This form of TOS occurs when one or more of the veins (venous thoracic outlet syndrome) or arteries (arterial thoracic outlet syndrome) under the clavicle are compressed.

Symptoms

TOS symptoms vary, depending on where the compression occurs. When nerves are compressed, symptoms of neurogenic TOS include:

  • Muscle wasting in the fleshy base of the thumb (Gilliatt-Sumner hand)
  • Numbness or tingling in the fingers or arm
  • Muscle pain or aches in the neck, shoulder, or hand
  • Weakened grip

Symptoms of vascular TOS include:

  • Bluish discoloration of the hand or lack of color (pallor) in the hands/fingers due to impaired circulation
  • Arm pain and swelling
  • Blood clot in veins or arteries in the upper area of the body
  • Weak or no pulse in the arm
  • Cold fingers, hands, or arms
  • Numbness or tingling in the fingers
  • Weakness of arm or neck
  • Throbbing lump near the collarbone

Causes

TOS is caused by the compression of the nerves or blood vessels in the thoracic outlet, just below the clavicle. The cause of compression can include:

  • Anatomical defects, such as an extra rib or an abnormally tight fibrous band connecting the spine to the rib
  • Poor posture, dropping shoulders, or holding the head in a forward position
  • Trauma, such as a car accident
  • Repetitive activity in the upper extremities
  • Pressure on the joints from obesity or carrying a large amount of weight
  • Pregnancy
  • Heredity

Diagnosis

Diagnosing TOS can be difficult, as symptoms can vary greatly and are often subjective.  It is not uncommon for TOS to be misdiagnosed as other conditions, such as carpal tunnel syndrome or cubital tunnel syndrome.  To diagnose TOS, a physician will perform a medical history review and physical examination. The examination will include an evaluation of the thoracic outlet, pulses, range of motion, and coloration in the arm, hand, or fingers.

Provocation tests are often used to rule our other causes of symptoms, and include the Roos Stress Test (also known as the elevated arm stress test), Adsons Test, Wright Test, and Eden Test. In these tests, a physician will ask the patient to move the arms, neck, or shoulder in various positions. Certain maneuvers can produce symptoms and blood vessel “pinching,” resulting in a loss of pulse.

A physician may also require additional screening to confirm the diagnosis of TOS, including:

  • X-rays: to reveal an extra rib or to rule out other conditions in the neck or spine that may be causing symptoms
  • CT Scan: to identify the location of the blood vessel compression
  • MRI: to determine the location and cause of the blood vessel compression or to reveal any congenital defects causing symptoms (such as an extra rib or an abnormally tight fibrous band connecting the spine to the rib)
  • EMG: to evaluate electrical activity of the muscles and identify any nerve damage
  • Nerve Conduction Study: to test and measure the nerves’ ability to send impulses to muscles in different areas of the body and to reveal nerve damage
  • Ultrasound: to see if the individual has vascular TOS or other vascular problems
  • Arteriography and venography: to look at blood flow and see if there is a compressed vein/artery or a blood clot

Treatment

Treatment of TOS can usually be successful with conservative measures. These treatments include:

  • Physical therapy
  • Anti-inflammatory medications, pain medication, or muscle relaxants
  • Clot-dissolving medication

More severe cases of TOS may require surgery, called thoracic outlet decompression.  This may include removing muscles or the first rib in order to spare injury to the affected nerve and blood vessels from ongoing compression. The surgeon may then repair or replace any damaged blood vessels. Vascular TOS is more likely to require surgery to resolve the symptoms.

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:

Mayo Clinic, www.mayoclinic.org
Medicine Net, www.medicinenet.com
Cleveland Clinic, www.clevelandclinic.org
Science Direct, www.sciencedirect.com
National Organization for Rare Disorders, www.rarediseases.org
Physiopedia, www.physio-pedia.com
John Hopkins Medicine, www.hopkinsmedicine.org

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Disability Insurer Profiles: MassMutual

Founded in 1851, Massachusetts Mutual, more commonly referred to as MassMutual, is one of the oldest insurance providers still in operation today. Currently, MassMutual is also one of the largest providers of insurance policies, with assets valued at about $247 billion and a total revenue of $21.7 billion in 2017.[1]

If you have a MassMutual policy, it is important to carefully evaluate and understand your policy’s riders and evaluate whether they apply to the entire monthly benefit or a smaller subset of the monthly benefit. For example, in the case of Colt v. MassMutual[2], the policyholder, a licensed pharmacist, developed a debilitating bone disease and subsequently filed a disability claim under his policy with MassMutual.

Prior to the onset of his disease, the pharmacist had purchased a Cost of Living Rider and a Lifetime Benefits Rider. After the claim was filed, the pharmacist argued that the Cost of Living increases should continue for the remainder of the claim, while MassMutual argued that the Lifetime Benefits Rider did not extend the Cost of Living increases beyond age 65.

After a complex analysis, the court ultimately determined that the pharmacist’s Cost of Living Rider was extended by the Lifetime Benefit Rider. However, this case illustrates why it is important to read your policy carefully when you receive it, to ensure that you have a clear understanding of the scope of your coverage.

Similarly, if your policy has multiple riders that provide additional benefits or features to the policy and you later on increase the base benefit amount under the policy, you should pay close attention to whether the additional benefits and features are being extended to the benefit increase as well as the base policy amount.

These are just a few examples of things to be aware of if you have a MassMutual policy or claim with MassMutual. MassMutual policies are not all identical, and they are updated frequently. Your policy may or may not include the provisions mentioned above. If you are considering filing a disability claim, you should consult with an experienced disability insurance attorney to learn more about your policy and any potential issues related to your particular claim.

 

[1] https://www.massmutual.com/~/media/files/financial%20documents/Statutory%20financial%20statements/Massachusetts%20Mutual%20Life%20Insurance%20Company/2017Q3_mmsub_stat.pdf.

[2] Colt v. Massachusetts Mut. Life Ins. Co., 29 Mass.L.Rptr. 547 (Super. Ct. 2012).

 

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The Challenges Faced By
Professionals Filing Mental Health Claims

With mental and substance abuse disorders being the leading cause of disability worldwide[1], insurance companies are very keyed into how they can save money on mental health claims. As we’ve discussed before, many policies, especially newer ones, contain mental health disorder and substance abuse limitations that expressly limit the amount of benefits the policyholder can receive (typically to 12 or 24 months), and some even contain exclusions that prevent policyholders from collecting benefits at for mental health conditions alltogether.

Even if your policy doesn’t contain these limitations, insurance companies subject mental health claims to close scrutiny, and some insurance companies have even established specialized departments that exclusively handle mental health claims.  These departments are made up of claims consultants who have additional, specialized training, vocational consultants, and in-house psychologists and psychiatrists. The primary goal of these departments is often closing claims by returning claimants to the work force.

While many professionals are able to return to work in their prior occupation after receiving mental health treatment, that is not always the best option for everyone. For some professionals—for example, the dentist with anxiety or the emergency room doctor with PTSD—even the thought of being forced to return to work can send them into a downward spiral, and undo any progress that they have previously made in therapy.

Oftentimes, the first thing that the insurer’s mental-health team will do is contact your providers and challenge the appropriateness of your treatment and/or push for a return-to-work timeline. If you’re treatment provider has never dealt with an insurance company before, he or she may feel pressure to push for unrealistic goals and/or exaggerate progress, which can in turn interfere with treatment and/or lead to a strained patient-therapist relationship. Consequently, it is important to find a treatment provider who will stand up to your insurer and provide a fair and realistic account of your progress. If an insurer is being particularly aggressive, it can also be helpful to have a disability insurance attorney step in and rein-in the scope of the insurance company’s investigation to an appropriate level.

 

Those suffering from a mental health disorder can find resources for immediate help at mentalhealth.gov.

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[1] 10 Facts on Mental Health, World Health Organization, http://www.who.int/features/factfiles/mental_health/mental_health_facts/en/index1.html.



How the Disability Claims Process Works, in a Nutshell

People often ask us “what is the claims process like?” and/or “what should I expect if I file a disability claim?” Obviously, each claim is unique, and how your particular claim will play out largely depends upon a wide range of factors, including your profession, your particular insurance company, the nature of your condition, when your policies were issued, and what the key definitions in your policy say, among other things. However, there are some basic aspects of the process that you should be aware of if you are considering filing a disability claim or wondering how the disability claims process works.

Obtaining the Claim Forms

The process for obtaining claim forms varies from company to company. Some companies provide forms online, and other companies require you to call in to request the claim forms. Recently, we have noted that several companies are starting to conduct information-gathering, recorded interviews when you call in for claim forms.

If you are not aware that this could be a possibility, you can end up being caught off-guard without a clear understanding of what your policies say or what the company can and cannot ask for when investigating your claim. Because of this, we advise that professionals at least speak with an experienced disability attorney before requesting claim forms so that, at a minimum, they understand how the process works before they make a call that can initiate a recorded interview.

Completing the Claim Forms

Typically, the initial packet of claim forms will contain several different forms, including paperwork that you must fill out, paperwork for your treating doctor, and oftentimes paperwork that must be completed by your employer. As the claim progresses, the company will require additional paperwork, which at the outset of a claim typically consists of a monthly progress report that must be completed by you and a monthly attending physician’s statement from your doctor.

Records Requests

After you submit the initial claim forms, your insurer will likely send a follow-up letter requesting additional records and documents. For professionals, this usually includes financial documents (such as tax returns), production codes, profit and loss statements, employment agreements, and practice sale documents, if applicable, among other things. Whether these requests are appropriate depends on the terms of your policy and nature of your claim (for example, whether you are filing a total disability claim, as opposed to a partial disability claim).

Interviews

In addition to the initial phone interview, the company may hire a field examiner to interview you in-person. This interview typically takes place at your attorney’s office, or at your home if you are not represented by an attorney. The company may also seek to interview your former co-workers and/or employers about your prior job duties, and may seek to interview your friends or family members about the impact your condition has had on your day-to-day life. Whether these types of interviews are appropriate depends on the particular issues at play in your claim.

Examinations

Almost every disability policy contains a provision that allows the company to have you examined as part of the claims investigation. However, different policies allow for different types of examinations. Some policies (typically older policies) only expressly provide for “physical” or “medical” examinations, while newer policies typically provide for a host of different types of exams, including mental exams, vocational evaluations, rehabilitation evaluations, functional capacity evaluations, and/or neuropsychological testing, in addition to physical exams. Again, whether an exam is appropriate depends on the particular facts of your case.

Surveillance

Many companies conduct surveillance at some point during the claim. This can include a review of your online presence (social media accounts, public record searches, etc.).

Elimination Period

Most disability policies require you to satisfy the policy’s elimination period before any benefits are due. Each policy will have a specific procedure for satisfying the elimination period, but in most instances you can only satisfy the elimination during periods of disability. So, put differently, even if your claim is approved at the outset, there will still be a period of time (e.g. 3 months) that you must be disabled before any benefits are due. This is important to keep in mind because many claimants expect to receive benefits right off the bat and don’t realize that, even in the ideal scenario where a claim is approved right away, it will be several months before they receive the first benefit payment.

This is not an exhaustive list of everything that can happen in the context of a disability claim, but it is a broad overview of some of the major aspects of the claims process. Some of the items in the list, such as the elimination period, apply to virtually every claim, while the likelihood of other items in the list occurring (such as medical exams) depends on the facts of your particular case.

Because of this, if you’re thinking about filing a claim, it is always a good idea to have someone who is familiar with the claims process (like an experienced disability insurance attorney) evaluate your specific situation, so that you can have a better sense of what to expect in your particular circumstances.