Significant Uptake in Physician Mental Health Claims
in the Wake of COVID-19

Physicians, dentists and and other doctors are susceptible to mental illness, burnout, and stress, given the demanding nature of the field.  This susceptibility has only become more pronounced in the face of the COVID-19 pandemic.  According to MGIS, a national insurance program manager, claims for mental and nervous conditions ranked third among the top causes of long-term absences from work. Others in the top five for doctors include cancer, musculoskeletal conditions, injury and nervous system conditions (e.g., multiple sclerosis, Parkinson’s disease).  This was an 85.8 percent increase from claims filed in 2019.

Recent studies throughout the course of the pandemic back up what MGIS data is showing.  A Yale School of Public Health survey showed high rates of depression and PTSD, with nearly one quarter of doctors showing signs of probable PTSD.  A Washington Post – Kaiser Family Foundation poll found that three in ten doctors and other health care workers have considered leaving their profession, 50 percent are burned out, and six in ten say stress from the pandemic has harmed their mental health.

As these studies show, stress, burnout and other mental illnesses have become an even bigger problem in the workplace during COVID-19—often leading to the need to miss work and sometimes the need to file a professional disability insurance claim.  However, as you might imagine, mental health claims are often subject to heightened scrutiny by disability insurance companies and can be more difficult to prove up given their subjective nature.  If you are a physician, dentist or other doctor with mental health concerns relating to COVID-19 and are and thinking of filing a claim, please feel free to contact one of our attorneys directly.

Sources:

Mental and Nervous Long-Term Disability Claims for Healthcare Professionals Jumped Significantly in 2020, Cision PR Newswire, August 17, 2021, https://www.prnewswire.com/news-releases/mental-and-nervous-long-term-disability-claims-for-healthcare-professionals-jumped-significantly-in-2020-301357045.html

Matt Kristoffersen, Burnout, Alcohol, PTSD: Health Workers Are Suffering, Yale School of Medicine, February 17, 2021, https://medicine.yale.edu/news-article/burnout-alcohol-ptsd-health-workers-are-suffering/

William Wan, Burned out by the pandemic, 3 in 10 health-care workers consider leaving the profession, The Washington Post, April 22, 2021, https://www.washingtonpost.com/health/2021/04/22/health-workers-covid-quit/

 

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Coronary Artery Disease

Coronary artery disease (CAD), also called coronary heart disease or ischemic heart disease, is the most common type of heart disease in the United States.  CAD is the result of plaque building up on the wall of the arteries that supply blood to the heart.  This buildup can cause the arteries to narrow over time, partially or fully blocking the blood flow (atherosclerosis).

As the arteries narrow, some people may begin to experience chest pain (angina) or shortness of breath while others may have no symptoms at all. A completely blocked artery will cause a heart attack.

Symptoms

Symptoms of heart attack include:

  • Chest pain or discomfort
  • Weakness, light-headedness
  • Nausea
  • Pain or discomfort in the arms or shoulder
  • Shortness of breath
  • Fatigue
  • Pain in the neck or jaw
Risk Factors

Risk factors for coronary artery disease include:

  • High blood pressure
  • High blood cholesterol levels
  • Diabetes
  • Being overweight or obese
  • Physical inactivity
  • High stress
  • Unhealthy diet
  • Smoking
  • Family history
  • Age (risk increase with age)
  • Sex
Diagnosis

Several different tests can be used to diagnose CAD, including:

  • Electrocardiogram
  • Echocardiogram
  • Exercise stress test
  • Chest X-ray
  • Cardiac catherization
  • Coronary angiogram
  • Coronary artery calcium scan
  • CT scan
Treatment

Treatment for CAD can include:

  • Medications
  • Procedures to restore and improve blood flow (angioplasty and stent placement, coronary artery bypass surgery)
  • Lifestyle changes (including a health diet, regular exercise, weight loss, and reducing stress)

For some, avoiding serious complications, including heart failure, may require stepping away from practice, even with treatment. If you have been diagnosed with coronary artery disease and are thinking that you may need to file a disability insurance claim, please feel free to contact one of our attorneys directly.

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

Sources

CDC

National Heart, Lung, and Blood Institute
American Heart Association
Mayo Clinic

 

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Have I Changed My Regular Occupation?

If you are a licensed dentist or physician and file a disability claim, will your insurance company recognize your occupation as a “dentist” or “physician”?  Not necessarily.

How is “Occupation” Determined?

Most disability policies look at what you are doing right before your disabling condition occurred (as opposed to your license or what you have done for the majority of your career) when it comes to defining your regular occupation. This can be problematic if you stop working, or change jobs or job duties prior to filing your claim.

One such example of this is the case of Hsu v. Northwestern Mutual Life.[1] Dr. Hsu, a physician specializing in interventional pain management, left his job to move to the west coast.  Before he resumed practicing in his new location, he began to experience symptoms of constant right elbow pain that was exacerbated by wrist extension or elbow flexion. He decided to have surgery and then returned to work on a trial basis at a new practice.

Unfortunately, the surgery did not prove successful. Dr. Hsu found himself unable to work and he filed a claim with Northwestern Mutual Life (NML). After reviewing his file, NML determined that Dr. Hsu did not have a “regular occupation” because he was not working when he became disabled. As a result, NML denied his total disability claim.

Do You Know How Your Policy Works?

It is not uncommon for us to see similar situations to Dr. Hsu’s, where a physician or dentist has taken an extended break (whether because of a disabling condition or for an unrelated reason) only to later realize they cannot return to work and needs to file a claim.  In fact, many policies have provisions that state if an insured is not working at the time of disability, their occupation will be considered that of a retired person.  Of course, it is much harder to prove up that you cannot do the normal tasks of a retired person versus not being able to perform the duties of a practicing physician or dentist.

Other mistakes include significantly modifying job duties (e.g. doing exams only instead of all facets of dentistry) or taking on a new or side job in an attempt to make up for lost income.  All these activities can significantly impact how your insurance company determines your occupation.

Oftentimes, dentists and physicians make this mistake because they assume that their policy only allows them to collect if they are severely injured or paralyzed and unable to work at all. However, many professionals have “own occupation” policies that protect them if they are unable to do their job, even on a part-time basis.

The Takeaway

In Dr. Hsu’s case, the Court indicated that whether or not Dr. Hsu had been a physician or had no regular occupation at the time of filing was debatable, and the case remains pending as of this writing. However, Dr. Hsu might have avoided the expense and stress of litigation if he had read his policy carefully,  complied with its requirements, and properly timed the filing of his claim.

If you have a disabling condition and are thinking about filing a claim, please feel free to contact one of our attorneys directly.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If your policy’s terms are not what you expected, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.

[1] Hsu v. Northwestern Mutual Life, C20-88 TSZ, 2021 WL 735374 (W.D. Wash. Feb. 5, 2021)

 

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Mental Health Issues in the Workplace

The Hartford, a provider of disability insurance, has released new research regarding mental health issues.  The study shows the prevalence of both mental illness in the workplace and a stigma that prevents those facing mental health challenges from accessing care.

According to the study, which polled both employers and employees, 70% of employers reported mental health challenges among their employees, with 72% saying that stigmas around mental health prevented care. Twenty-seven percent of employees said they struggle with depression or anxiety most days or a few times a week, which was up 20% from March 2020.

Further, according to the study, there is a disconnect in how employers perceive the mental health issues versus how employees do.  For example, while 80% of employers said their company culture has been more accepting of mental health challenges in the past year, only 59% of workers agree.  Similarly, 78% of employers said workers had flexibility in their schedule to get mental health help, but only 58% of workers agreed.

The study also highlighted the economic impact of untreated conditions in the workplace, with 31% of employers reporting that employee mental health strain is having a significant or severe financial impact on their company.  This is a 10-point increase from a March 2020 survey.  Despite this increase, 70% of employers and 62% of employees felt that the workplace will become less stigmatized as a result of the pandemic.

Depression, anxiety, and burnout can all be causes of missed work and, in some, can lead to the need to file a disability insurance claim. However, such cases can be notoriously hard to prove up.  If you have mental health concerns and are considering filing a claim, please feel free to contact one of our attorneys directly.

Source:

The Hartford Study: Majority of Employers Recognize Mental Health As A Significant Workplace Issue, Report Stigma Prevents Treatment, businesswire, https://www.businesswire.com/news/home/20210622005719/en/The-Hartford-Study-Majority-Of-Employers-Recognize-Employee-Mental-Health-As-A-Significant-Workplace-Issue-Report-Stigma-Prevents-Treatment

 

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I’ve Been Paid Benefits For Years–
Why is My Insurer Asking for More Information?

If your disability insurer has reassigned your claim or is asking for more information than usual, your claim may be targeted for termination.

If you’ve been on claim for a while, it is easy to become complacent and forget that your disability insurer is constantly evaluating whether you remain entitled to benefits. However, if you do not take care to meet your ongoing proof of loss requirements, you may find yourself facing a claim termination the next time your insurer conducts a review.

Why Do Insurers Reassign and Revisit Claims?

Sometimes, insurers will conduct broad reviews of all ongoing disability claims for financial reasons, to see if they can save any money by denying claims that they are currently paying.

On an individual basis, claims may also be singled out for heightened review after an insurer does online or in-person surveillance, or if an insurer requests medical records and the most recent records are limited or vague. In this second instance, an insurer may challenge whether the policyholder has met the policy’s ongoing care requirements. Another common example that draws heightened attention to a claim is changing jobs or job duties during a claim.

My Insurer Wants to Conduct a Medical Exam–Is this a Bad Sign?

One example of this is the case of Jue v. Unum.[1] Dr. Jue, a dentist, was diagnosed with De Quervain’s Tenosynovitis. She became unable to work due to swelling and pain in her wrists and filed a claim under her Unum disability policy.

Unum approved the claim and, from 1998 to 2004, Dr. Jue submitted regular statements from herself and her physicians. These reports confirmed that her condition remained disabling.  Then, from 2004-2011, Unum only required annual claimant statements and monthly income statements.

Dr. Jue changed doctors in 2012, and Unum began asking for physician statements from the new doctor. Then, in 2015, Dr. Jue took on some additional work responsibilities and was compensated for time spent on computer training. At the time, she was practicing as a dentist part-time, and did not want Unum to count the computer training income when calculating her partial disability benefits. This prompted Unum to reassign her claim to its “validation unit.”

In addition to evaluating the new source of income, Unum’s validation unit revisited the underlying medical condition. It referred her file to a physician to conduct a paper review and then required Dr. Jue undergo an independent medical examination. Unum’s doctor told her that she needed to have surgery, Dr. Jue refused, and Unum terminated her benefits, after paying her for over a decade.

The Takeaway

This case highlights the importance of always having strong evidence to support your claim, even if your insurer is not asking for it as frequently. Most disability policies pay on a monthly basis. Consequently, insurers can (and do) conduct renewed investigations, often without warning. Even if your condition has not improved, you may still face a termination (or lawsuit) if you are not prepared to prove you qualify for ongoing benefits.

If your insurer has increased proof of loss requests and you fear your claim may be being targeted for denial, please feel free to contact one of our attorneys directly.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your claim has not received a full and fair review, an experienced disability insurance attorney can evaluate your claim and help you determine what options are available.

[1] Jue v. Unum Group, Case No. 19-CV-08299-WHO, 2021 WL 427640 (N.D. Cal. Feb. 8, 2021).

 

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My Disability Company Told Me To Have Surgery–
Can They Do That?

Can my insurance company make me have surgery or dictate the terms of my treatment?

This is a common question, and a complex one. The answer depends on the terms of your policy and your disabling condition. Recently, insurers have become more aggressive in this area. The case of Jue v. Unum is one such example.[1] 

What if My Doctor Disagrees About Surgery?

Dr. Jue, a dentist, filed a claim in 1991 based on pain and swelling in both of her wrists, attributable to De Quervain’s Tenosynovitis.  Dr. Jue’s physicians indicated that surgery was an option in some cases but more conservative treatment was warranted.  Dr. Jue was reluctant to have surgery given her age and surgery risks.

Notably, Dr. Jue was on claim for many years before Unum brought up surgery, including a prolonged period from 2004-2011. Despite knowing that surgery was a potential option for De Quervian’s patients, Unum continued to pay benefits for a fifteen-year period.  In fact, one Unum representative even told Dr. Jue in a phone call that they could not force her to have surgery.  Yet, in 2017 Unum took the opposite position and told Dr. Jue that she had 90 days to schedule her surgery. If she did not, Unum told her that it would terminate her claim for failure to “obtain appropriate treatment for her condition.”

In response, Dr. Jue returned to one of her treating physicians, Dr. Hsu. Dr. Hsu opined that Dr. Jue had legitimate reason for concern, because no surgeon could guarantee that surgery would improve her condition. Dr. Hsu also stated that no surgeon could guarantee that surgery would not make her condition worse.  Unum then secured its own set of physician opinions who said that surgery was the next appropriate treatment, and terminated the claim in spite of Dr. Hsu’s opinion.

The Takeaway:

As of the date of this post, Dr. Jue’s case remains ongoing. However, her case shows that insurers are willing to make surgery a requirement for ongoing benefits. This does not necessarily mean the insurer is right, but it may mean that a lawsuit is necessary to resolve the question.

If your insurance company is pressuring you to have more invasive treatment than you are comfortable with, please feel free to contact one of our attorneys directly.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your claim has not received a full and fair review, an experienced disability insurance attorney can evaluate your claim and help you determine what options are available.

[1] Jue v. Unum Group, Case No. 19-CV-08299-WHO, 2021 WL 427640 (N.D. Cal. Feb. 8, 2021).

 

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Disability Insurance: Do I Really Need It?
A Disability Insurance Attorney’s Perspective

Dentists have unique risk factors as part of their occupation that can make them susceptible to disabilities, including musculoskeletal injuries.  Often, the nature of these disabilities can present challenges if and when it comes time to file a claim with your disability insurer.

Attorney Derek Funk’s recent article in the Utah Dental Association’s publication, UDA Action, discusses the most common reasons dentist file for disability, things to be aware of both before and during the course of a claim, and how to know if you have a complex claim and may need to speak with a disability attorney.

Click here to read the full article.



The Importance of Keeping a
Copy of Your Policy: A Case Study

Do you have a copy of your disability policy?  And, if you think you do, do you know where it is?

Many professionals file their policies away and never look at them again until something happens and they may need to file a claim. By then, the policy has been misplaced or lost, leaving them in the dark and unable to verify  how their coverage works.

This can lead to costly coverage disputes with insurers, particularly if the policy in question is an older policy. Some older policies were underwritten by companies that no longer exist, or have since sold their disability business to other companies. As a result, questions can arise regarding the terms of an older policy, particularly if the company who issued the policy is not the same company administering the claim.

One such example of this is the case of Falcon v. Northwestern Mutual Life[1]Dr. Falcon was a plastic surgeon who filed a disability claim based on vision loss. Dr. Falcon believed that he was entitled to lifetime benefits because he had become disabled prior to age 65. However, he did not keep a copy of his policy.

In response, Northwestern Mutual claimed that the policy did not pay lifetime benefits unless the policyholder became disabled prior to age 60. Notably, Northwestern Mutual could not produce exact copies of policies either. However, they did have a record of basic information about the features of the policy and used that recreate the policy piecemeal. Unsurprisingly, the copy policies supported Northwestern Mutual’s position.

At present, this case is still pending.  It may require a trial to resolve, as neither side is able to definitively show they are right. However, if Dr. Falcon had simply kept a copy of his policy, the matter may have been resolved without the need for a lawsuit.

You can save yourself from this same headache by keeping a copy of your policy and knowing what it says.  If you have a question about the terms of your policy or feel that your insurer is misapplying the terms of your policy, please feel free to contact one of our attorneys directly.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your claim has not received a full and fair review, an experienced disability insurance attorney can evaluate your claim and help you determine what options are available.

[1] Falcon v. The Northwestern Mutual Life. Ins. Co.,  Civil Action No. 19-404, 2020 WL 7027482 (W.D. Pa. Nov. 30, 2020).

 

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Insurance Company Tactics:
The Dual Occupation Defense

Dentists and physicians facing a disabling condition often look for other jobs to supplement income. Depending on the terms of the underlying policy, this can prompt insurers to raise a “dual occupation” defense.

One such example is the case of Lemons v. Principal[1]. Dr. Lemons was an OB/GYN who had also worked as a claims consultant for a health insurance company and as an addictions counselor. Dr. Lemons claimed disability based on a hand tremor, claiming that the tremor prevented him from safely practicing as an OB/GYN.

Principal denied Dr. Lemons’ claim, claiming his occupation under the terms of his policy encompassed all of the jobs he had been engaged in. Principal asserted that Dr. Lemons was not totally disabled because the tremor did not impact the ability to act as a consultant or work as a counselor. For his part, Lemons argued that his regular occupation was solely that of an OB/GYN.

The court determined that, under Alabama law, words must be given their common, everyday meaning and interpreted as a reasonable person in the insured’s position would interpret them.  Based on this, the court determined that the most natural reading of regular occupation was that “the term refers to an insured’s primary job or discipline.” The court further explained that it read the “regular occupation rider’s use of the singular ‘your regular occupation’ to mean that the policy contemplates that the insured has only one primary job.”

Lemons was successful, in part, because his regular occupation rider used the singular “your occupation.”  However, insurers have updated and changed their policies to make the definition of occupation more robust. Many companies have now replaced “occupation” with “occupation(s)” in an effort to preserve their ability to use a “dual occupation” defense to avoid payment.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your claim has not received a full and fair review, an experienced disability insurance attorney can evaluate your claim and help you determine what options are available.

[1] Lemons v. Principal Life Ins. Co., Case No. 2:18-CV-01040-CLM, 2020 WL 6273741 (N.A. Ala. Oct. 26, 2020).

 

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What If Surgery Doesn’t Work?
An Overview

For certain conditions, surgery may be required if symptoms are severe. And surgery can be an effective treatment for many conditions. For example carpal tunnel syndrome. But what if surgery doesn’t work? If a dentist or physician hasn’t planned for this, it can be a challenging time.

There can be numerous reasons why surgery doesn’t work – including a botched procedure or waiting too long to have the surgery.  In the carpal tunnel example, symptoms can be due to something else or a co-morbid condition (e.g. cubital tunnel syndrome, arthritis, cervical radiculopathy).

With disability insurance claims, insurers will often recognize a recovery period for something like carpal tunnel surgery as a period of disability. However, they also have limits on how long that period can last (sometime called “durational guidelines”).

Once this recovery period is up, insurers often begin to push you to go back to work – even if you are not ready. For example, they may call your doctor and press for a firm “return to work” date. Or, they may request an Independent Medical Evaluation (IME).

It can be difficult to prove that a surgery didn’t work. Particularly if your ongoing symptoms are largely subjective in nature (for example pain or numbness). Without evidence of continued symptoms or a diagnosis of co-morbid conditions, a claim may be denied or terminated. Consequently, the fight to maintain benefits most often comes after surgery.

Each case individual case is different.  If you’ve had or are planning on surgery, and are concerned about its impact on your claim, please feel free to reach out to one of our attorneys directly.

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What is a Functional Capacity Examination (FCE)?
An Overview

Most policies now allow for insurance companies to request claimants undergo various examinations. One example is the Functional Capacity Evaluation, or FCE.

What is an FCE?

FCEs are usually conducted by a occupational or physical therapist. They generally last between 4-6 hours.  However, they can be spread out over multiple days.

You will have to complete intake paperwork.  The examiner may monitor you to see how long it takes for you to complete the paperwork.  Including whether it is difficult or painful for you to sit.

Once the FCE formally begins, it tests the following:

  • Your ability to lift, push, pull, and carry objects;
  • Your ability to reach, stoop, kneel, crouch, and crawl; and
  • Your ability to handle and manipulate small objects.

These tests evaluate your dexterity, coordination, and endurance. Further, they evaluate job-specific functions. The examiner should also be evaluating your pain levels during each test.

Once complete, the report will go to your insurance company. Then, your insurance company will evaluate it to determine if you are physically unable to perform duties of your occupation. A properly done FCE can help your claim. However, your insurance company may use them to try and deny your claim.

What Can I Do?

You can take certain steps to ensure the FCE doesn’t negatively impact your claim:

  • Request a copy of the report;
  • Be clear and precise about any pain you feel;
  • Do not exaggerate;
  • Document any pain or other symptoms you experience after testing is over; and
  • Follow-up with your own doctor about symptoms during and after the exam

An experienced disability insurance attorney can help you determine:

  • What type of evaluation was performed;
  • The methodology and criteria used; and
  • It’s accuracy in measuring your abilities.

Finally, if you have or are scheduled to have an FCE and have questions, please feel free to contact one of our attorneys directly.

 

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How Do Partial Disability Benefits Work?

Some disability policies allow for recovery of partial disability benefits if you are still able to work on a limited basis. In newer disability policies, this feature is typically added as a rider that you must choose to add to the base policy. If your policy does not have a partial disability or residual disability rider, it may only cover total disability.

What is the Difference Between Total Disability and Partial Disability?

Individual policies sold to physicians and dentists typically define “total disability” as the inability to perform the material and substantial duties of your occupation.

In contrast, partial disability benefits are designed to supplement your income if your ability to work is limited by a sickness or injury. After the elimination period has been satisfied, benefits are due for each month that you can prove both that you have (1) suffered a loss and (2) that the loss was due to sickness or injury. This second requirement is sometimes referred to as establishing a “demonstrated relationship” between the loss and the disability.

How Do I Collect Partial Benefits?

Most older disability policies require a threshold loss in income in order to qualify for partial benefits, typically around 15 to 20%. New policies can define loss in other ways, including losses in hours or losses in the ability to perform a certain percentage of your material duties.

When reviewing your policy, it is also important to pay attention to whether the requirements for collecting change over time. For example, many partial disability riders outline different rules for collecting during the first 6 or 12 months of disability, versus the remaining months of disability.

How Do I Know if I Have a Partial or Total Claim?

Because each policy defines partial disability differently, the first step is to locate the definitions for total disability and partial disability.

Once you know your policy’s requirements, the next step is evaluating factors such as the nature of your condition, the extent of your limitations, and whether you meet your policy’s loss thresholds. Another important consideration is whether you are putting your own health or patients’ health in jeopardy by continuing to practice.

In some instances—such as claims involving slowly progressive conditions like cervical radiculopathy or an essential tremor—it can be difficult to evaluate whether you are partially or totally disabled and/or whether a partial disability has progressed to the point where it is now totally disabling.

As each claim is different, there is no one-size fits all answer to this question, and whether you are partially or totally disabled will come down the particular facts of your disability claim and your particular policies’ requirements. If you have questions about your claim or potential claim, please feel free to contact our attorneys directly to set up a consult.

 

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What is an Independent Medical Examination (IME)?
An Overview

Your insurance company may ask you to undergo an Independent Medical Examination (IME).

Generally, a physician conducts the IME. Often, the company insists on picking the doctor. Broadly speaking, your insurer may request an IME if it does not agree with your doctors. Or if there is limited medical information in your file.

However, IMEs are not always truly “independent.” Often, insurance companies request IMEs in order to deny your claim. For example, the IME doctor’s primary income may come from these types of exams. Additionally, companies may unfairly use the same doctor over and over again in different claims.

What Can I Expect During an Independent Medical Examination?

  • Typically, the exam starts with an interview.
  • Often, the doctor starts with a general physical examination.
  • Next, the IME focuses on your disabling condition.
  • You may be asked to bend, lift or perform movements.
  • Throughout, the doctor looks for inconsistencies or signs of exaggeration.
  • After the exam, the doctor will prepare a report for your insurance company.

What Can I Do if I Have an IME?

First, review your policy to see if you are required to undergo an IME. Next, complete any intake forms in advance. At the exam:

  • Be cooperative and open;
  • Ask questions if you don’t understand something;
  • Discuss your symptoms fully and honestly; and
  • Connect your symptoms to your job duties.

If you are concerned about the company’s motives, talk with an attorney. A disability insurance attorney can help:

  • Determine what your policy actually requires;
  • Limit the test to certain parameters;
  • Verify the doctor’s credentials;
  • Record the exam;
  • Accompany you to the exam; and
  • Review the final report for accuracy.

I’ve you’ve been scheduled for an IME and have questions, please feel free to contact one of our attorneys directly.

 

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Insurance Company Tactics:
Conducting Multiple Paper Reviews

Insurance companies typically start their claim investigations by requesting forms and medical records from your treating provider(s). In order to deny a claim, they may go to great lengths to dismiss and ignore even the most supportive of records.  One way they do this is by using consultants to conduct paper-only reviews of the insured’s file.

One such example of this is Allen v. MetLife[1], where multiple consultants were used to try and undercut Linda Allen’s supportive physician’s statements and treatment records.  Allen, a highly educated professional, was exposed to toxic mold at her workplace and developed a myriad of symptoms/diagnoses as a result, including chronic rhinosinusitis, mold allergy, chronic fatigue disorder, neurocognitive disorder, vertigo, reactive airway disorder, depression, and anxiety disorder.

Although MetLife’s own doctor hired to examine Allen in-person concluded that her symptoms were “quite enough to limit her daily functioning”, MetLife denied her claim. In doing so, MetLife chose to place more weight on the multiple consulting physicians who only conducted paper reviews of Allen’s file. Alarmingly, one physician made several factual mistakes in his report (including errors in the names and types of medications Allen was taking) and another only reviewed a portion of Allen’s records.

Additionally, the Court noted that at least two of the reviewing doctors indicated a need for additional information. However, MetLife’s claim file revealed that MetLife did not share additional records received from Allen with its consulting doctors or ask its doctors to update their findings.

While the Court recognized “the importance of independent medical reviews” it also recognized the limitations of such reviews by doctors who did not examine a patient, going on to say “the mere fact that independent medical specialists were consulted does not automatically equate with a deliberate, reasoned process and substantial evidence.”

While the Court reversed MetLife’s wrongful denial and Allen was ultimately successful, it took litigation (which can often be costly and time consuming) to expose MetLife’s improper tactics and overturn MetLife’s denial of her legitimate claim.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your insurer is not evaluating your claim under the proper standard, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.

[1] Allen v. MetLife, No. 4:06-CV-175-H, 2008 WL 11429626 (E.D.N.C. March 31, 2008)

 

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Cigna Sells Group Disability
Businesses to New York Life

Cigna has now sold its group life, accident, and disability insurance business to New York Life in a $6.3 billion deal, initially announced in December 2019. The new business has been rebranded as New York Life Group Benefit Solutions.

This acquisition adds approximately 3,000 employees and over 9 million customers for New York Life, making it one of the top five insurers across group life, accident, and disability insurance.

Cigna will put the sales proceeds towards repayment of debt and share repurchase, and both companies will participate in a multi-year collaboration.

 

Sources:

Mallory Hackett, Cigna officially sells group life, accident and disability insurance business to New York Life, Healthcare Finance, Jan. 4, 2021

New York Life Completes Acquisition of Cigna’s Group Life and Disability Insurance Business, Businesswire, Dec. 31, 2020

Anusuya Lahiri, New York Life Snaps Up Group Life & Disability Insurance Business From Cigna For $6.3B, Nasdaq, Jan. 3, 2021

 

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Am I Under Surveillance?
An Overview

What Kind of Surveillance Do Insurance Companies Use?

If you’ve filed a claim for individual disability insurance, you will likely be under surveillance at least once.

Insurance companies use a variety of tactics to surveil claimants. For example:

  • Monitoring your online activities, including social media;
  • Stakeout operations and tailing;
  • Contacting friends or family members to try and gather information about you;
  • GPS and cell phone tracking;
  • Using drones or stingrays;
  • Pretexting;
  • Conducting an interview at your house; and
  • Using questions on claim forms to try and learn your schedule.

When Are Insurance Companies Watching?

Furthermore, there are certain times surveillance may occur more often.  For example:

  • During holidays;
  • On the claimant’s birthday;
  • Over weekends;
  • Near the end of fiscal quarters; and
  • Any time they have a chance to catch a claimant involved in physical activity (based on information provided by the claimant).

These are popular times because they are often scenarios where a claimant may push him or herself more than normal, especially in the context of physical activity. The point of this surveillance is to “catch” you doing activities that undercut your disability claim. Unfortunately, it is not uncommon for the insurance companies to take things out of context.

Using surveillance is not necessarily illegal. However, sometimes insurance companies cross boundaries. Understandably, it can be alarming to think about being under surveillance. And sometimes, repeated surveillance can mean your insurance company is targeting your claim for denial.

For this reason, it is important to be aware. An experienced disability insurance attorney can help if you feel your claim may be targeted for denial. Therefore, if you have questions, please feel free to contact one of our attorneys directly.

 

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Unum Announces Reinsurance Deal

In December 2020, Unum Group announced a reinsurance transaction with a subsidiary of Global Atlantic (Commonwealth Annuity and Life Insurance Company) in a coinsurance agreement. The closed block of business is backed by approximately $7.1 billion in reserves.  Unum will pay Global Atlantic a fee of around $376 million to reinsure about three quarters of the in-force policies in the closed block.

Global Atlantic’s primary focus is on selling life insurance and annuities, as well as reinsuring other businesses. Unum subsidiaries ceding individual disability business to Global Atlantic include Unum Life Insurance Company of America, Paul Revere Life Insurance Company, and Provident Life and Accident Insurance Company. Unum is also seeking permission from the original writers of some policies written by other companies to include them in the deal.

Around 95% of the affected policyholders are collecting benefits, while the remaining are not on claim.  Unum will continue to administer claims made under the policies.

Sources:

Allison Bell, Unum Picks Global Atlantic for $7.1B Reinsurance Deal, ThinkAdvisor, December 17, 2020.

Unum Press Release, Unum Group Announces Reinsurance Transaction with Global Atlantic on $7.1 Billion Closed Individual Disability Block, December 18, 2020.

 

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Can You File a Disability Claim for Hearing Loss?

According to the CDC and the National Institute for Occupational Safety and Health (NIOSH), hearing loss is the third most common physical condition among adults, with 24% of hearing difficulty among U.S. workers caused by occupational exposure.[1]

While one associates work-related hearing loss with careers like construction, studies have shown that the rates of hearing loss and tinnitus among dentists are double that of the general population, as a result of noise exposure from dental tools (such as high-speed handpieces).[2]  Unaided hearing loss has also been linked to increased depression, social isolation, and hospitalization. Further, it can result in reduced motor coordination, impaired cognition, learning, and memory.[3]

Like the two other most common disabling conditions experienced by dentists, musculoskeletal issues and vision loss, hearing loss and tinnitus are often slowly progressive and degenerative conditions—making it difficult to determine when and if symptoms have reached a level to prevent a dentist from safely practicing.

Hearing loss typically comes on gradually and, as it worsens, dentists may take steps to mitigate exacerbation of symptoms by either reducing the hours they work or avoiding doing procedures that exacerbate symptoms.  However, this can be problematic from a claims perspective because insurance companies will typically review dentists’ CDT codes to determine if they can argue that the dentist has modified his or her occupation.

If you are a dentist with a hearing condition that you feel may begin to compromise your ability to work, an experienced disability insurance attorney can help you evaluate whether you have a claim under your policy and guide you in preparing a transition plan so that, in the event you have to file a claim down the road, you are prepared and have not jeopardized your ability to collect.

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.

[1] Occupational Hearing Loss (OHL) Surveillance National Inst. for Occ. Safety and Health, last reviewed Dec. 9, 2019, https://www.cdc.gov/niosh/topics/ohl/default.html

[2] Ian D. Murray, BA, HIS, AHIP, IHS, Hearing Loss and Tinnitus Among Dentists, 73 The Hearing Journal, 10, January 2020, https://journals.lww.com/thehearingjournal/fulltext/2020/01000/hearing_loss_and_tinnitus_among_dentists.3.aspx

[3] Id.

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What is a COLA Rider?
An Overview

What is a COLA Rider?

Riders expand or limit coverage on a policy.  Usually, they are found at the back of a policy.

Adding riders can impact premium amounts. A Cost of Living Adjustment (COLA) rider is one of the more common riders added to disability insurance policies.

The cost of living typically goes up over time. Therefore, a COLA helps your benefits keep pace. Under most policies, the adjustment is made yearly.  The amount of the increase is calculated as a fixed percentage or based on the Consumer Price Index. However, insurers sometimes cap the overall increase in benefits.

COLAs are most beneficial to younger claimants. Younger claimants can be on claim for decades. Without a COLA, their benefit amount would become less effective over time.

Not All COLAs are the Same

COLAs are not the same across the board. Typically, COLAs kick in after a year of being on claim. However, sometimes there is a longer waiting period.

COLAs also can be limited in other ways. Sometimes, a cap is set on the amount of increases over the life of a claim. For example, increases may only be made for five years or to a certain age. A COLA rider may expire at age 65, even if your policy has lifetime benefits.

Some plans also set a maximum benefit amount. This means, if you reach this amount, a COLA will not be applied. This type of provision is typically found in employer-sponsored plans. Because of this, it is important to read your policy carefully. In some policies, limitations like maximum benefit amounts may be in a different part of the policy. So, even if you read the entire rider, you may not have a full understanding of your COLA.

If you are on claim, and have a question about how COLAs work, please feel free to contact one of our attorneys directly.

 

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Can I File a Disability Claim for
Breathing Problems Due To COVID-19?

While it may be some time before we fully understand COVID-19 and its long-term impact, experts have identified certain long-term complications from the virus, including breathing problems.

As COVID-19 is a respiratory disorder, it is no surprise that the lungs can be permanently damaged by the virus. Pneumonia associated with the disease can cause long-standing damage to the alveoli (tiny air sacs) in the lungs. Build-up of scar tissue can then lead to long-term breathing problems, including decreased lung function and decreased exercise capacity. Risks of this complication are highest among those with underlying conditions such as lung disease, hypertension, and obesity.[1]

Such disorders can be problematic for occupations that require mask-wearing, such as dentists and surgeons. Healthcare workers, including dentists, are also often most at risk for contracting COVID-19, due on their physical proximity to others and exposure to diseases[2].

In March of 2018, the CDC reported on a cluster of patients (dentists and dental workers) who were treated at a specialty clinic in Virginia for chronic, progressive lung disease, specifically idiopathic pulmonary fibrosis. The CDC said that occupational exposure was a possibility, stating “[d]ental personnel are exposed to infectious agents, chemicals, airborne particulates, ionizing radiation and other potentially hazardous materials. . .[i]nhalational exposures experienced by dentists likely increase their risk for certain work-related respiratory diseases.”[3]

Whether you can file a claim for COVID-19, a resulting complication, or a co-morbid condition depends on the terms of your policy and your unique circumstances. If you have questions about your particular situation, please feel free to contact one of our attorneys directly.

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.

[1] Mayo Clinic.

[2] Lazaro Gamio, The Workers Who Face the Greatest Coronavirus Risk, The New York Times, March 15, 2020.

[3] CDC reports ‘cluster’ of dental professionals diagnosed with lung disease, ADA News, March 13, 2018.

 

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