Lifetime Benefits, Part 2 – Graded Lifetime Benefits
In our last post we discussed how it can be difficult to save for retirement if your only income is your monthly disability benefits. One way to help ensure financial security into retirement age is to purchase a lifetime benefit option with an individual disability insurance policy. While older policies often featured full monthly disability benefit payments for life, newer policies insert qualifiers that limit whether a claimant will actually receive the full benefit amount for his or her lifetime. Our last post looked at the injury versus sickness limitation. In this post, we will be taking a look at another provision that limits lifetime benefits: the graded benefit rider.
Graded Lifetime Benefit Riders
Under the graded benefit rider, claimants receive benefits for life, provided they are disabled prior to a specified age and remain continuously totally disabled. However, the amount of the monthly benefit they receive varies based on how old the claimant is at the onset of his or her disability.
For example, a disability insurance policy may have a benefit period that ends at age 65, with a graded lifetime benefit rider (sometimes called a “lifetime extension for total disability”) that will pay 100% of monthly benefits for life if the policyholder is disabled prior to age 46. However, if the policyholder becomes disabled after age 46, his or her lifetime benefits will only be a certain percentage of the monthly payment.
Below is a provision from an actual policy, illustrating how benefit amounts are calculated under this type of rider:
Using this chart as an example, if your benefit payments are $10,000 per month and you become totally disabled at age 46 (100% under the policy) your disability insurance company will continue to pay you $10,000/month after you turn 65 for the rest of your life. If you become totally disabled at age 55, the percentage of monthly indemnity payable would drop to 50% and your disability insurance company would pay you $5,000/month after you turn age 65. If you don’t become totally disabled until age 64, the amount payable would only be 5% of your monthly disability benefit. In other words, you would have a year or less of monthly payments of $10,000, followed by monthly payments of $500.
While a graded lifetime benefits rider is one way to ensure that you continue to receive disability income after your standard benefit period ends, you must keep in mind that these payments may not provide much income if you become disabled later on in life.
Further, in order to achieve lifetime benefits under this rider, you must remain totally disabled. So, for example, if you return to work, were pushed off claim, or went into residual disability claim status, you lose the lifetime benefits. And even if you are later able to reestablish total disability, the lifetime benefit will be a lower percentage of the monthly benefit, because you will have re-set your total disability date for purposes of calculating your monthly benefit under the rider.
Lifetime benefits offer a way for policyholders to continue to collect at least some income after the benefit period of their disability insurance policy ends. However, when choosing a disability insurance policy, physicians and dentists must carefully consider their age at the time of purchase, premium amounts, and the policy language before buying a policy. Knowing how your policy’s lifetime benefits work is an important step in planning for your financial future.
In our next post we will look at another option individuals have to supplement their retirement income: the lump sum benefit rider.
Lifetime Benefits, Part 1 – Injury v. Sickness Limitation
Having a disability insurance policy is an important step in protecting your financial security and ensuring a monthly source of income if you are forced to step away from practicing as a dentist or physician and file a claim due to a disability. However, as we’ve discussed before, your monthly disability benefits typically will not match the monthly income you were earning as a doctor, dollar for dollar. As a result, you may not have any funds left over, after your monthly expenses, to save for retirement. This can be problematic since many plans have a benefit period ending at age 65 or 67, but the average American life expectancy is around 79.[1]
There are a few options residents or doctors have when buying a disability insurance policy that can help ensure financial stability past retirement age. One option is selecting a policy with a lifetime benefit rider. Older disability insurance policies, from the 80’s and 90’s, were often drafted in policyholders’ favor and a lifetime benefit provision meant just that—full monthly benefits would be paid out until a claimant’s death. Many newer disability insurance policies still offer an option to purchase “lifetime benefits”, but there are additional qualifiers in the policy language that dictate the amount of the disability benefit the claimant will receive, or whether he or she will receive lifetime benefits at all. In our next few posts, we will look at two common lifetime benefit limitations that are common in newer disability insurance policies. In this post we will examine the injury versus sickness limitation.
Injury v. Sickness Limitation
Under some policies, the nature of your disability (i.e. whether your disability is caused by an “injury” or by “sickness”) can determine whether your benefits will last a lifetime. Here’s an example of such a provision, taken from an actual policy:
As you can see, under this policy’s language, you only receive lifetime benefits if your disability stems from an injury occurring before age 65. Further, no matter how permanent a sickness is, the policyholder will not be eligible to receive lifetime benefits under this disability insurance policy.
In some instances, it is very straightforward to determine when a disabling condition will be classified as an injury (e.g. the inability to walk after a car accident) or as a sickness (e.g. Parkinson’s disease). But in other instances, the distinction between the two becomes less clear and, in many instances, litigation is required to resolve the issue. If the date of an injury is not well-documented, or your limitations arguably have multiple causes, the insurance company will oftentimes elect to pay disability benefits under the sickness provision of your disability insurance policy, so they don’t have to pay lifetime benefits.
This provision highlights the importance of carefully documenting and filing your disability claim from the outset, in order to prevent any ambiguity in the nature of a disabling condition. It also highlights the importance of understanding the provisions of your disability insurance policy you are being paid under, so that you are not caught unawares when your benefits (which you thought were lifetime benefits) are cut off after years of receiving benefits.
In our next post we will discuss another provision that limits lifetime benefits—the graded lifetime benefit rider.
[1] The World Bank, Life expectancy at birth, total (years), https://data.worldbank.org/indicator/SP.DYN.LE00.IN
The Importance of Regularly Reviewing Your Disability Policy
The new year is often a time for making resolutions and planning for the future. This should include reviewing your financial situation, including assessing whether you will be adequately prepared in the event that you become disabled and have to stop practicing. We recommend that you make a periodic review of your disability policies and evaluate:
- What type of policy(ies) do I have?
- Do I understand the terms and provisions of my policy(ies)?
- How much coverage do I have?
- Do I have enough coverage?
- Do I qualify for any increase options?
- Should I buy an additional policy(ies)?
Many physicians and dentists purchase their policies as residents or when they are first establishing their practice, and then file their disability insurance policies away and don’t think about them again until the unexpected happens and they need to file a disability claim. This is problematic, because financial needs and obligations change over time, and the income and standard of living for a resident is vastly different than that of a physician with a family 20 years down the road.
While insurance companies’ underwriting standards are typically structured in a way that prevents you from collecting the exact same amount of monthly income you were making pre-disability, your goal should be to get as close as possible. In other words, if you are a dentist earning $20,000 a month and need to file a claim, you don’t want to have to end up relying on a disability policy with a monthly benefit of $5,000 as your primary source of income.
Often disability insurance policies have future increase options that allow you to purchase additional coverage without changes to the terms of the existing policy. Typically, these options will only be available during certain discrete time periods set forth in the policy, so it’s important to read your disability insurance policy carefully to make sure you don’t miss out on the opportunity to take advantage of an increase option.
If your disability insurance policy does not have increase options and you’ve outgrown the monthly benefit amount, you can also purchase another policy to increase the total coverage you would receive if you filed a disability claim. However, if you’re going to be purchasing a new policy, you need to keep in mind that you must purchase a disability insurance policy that compliments you’re existing coverage, and does not cancel out your other policy or policies.
For example, some disability insurance policies contain provisions stating that a claimant cannot collect total disability benefits if he or she is working in another profession (a “no-work” provision). Other policies require the policyholder to work in some other capacity, in order to collect total disability benefits (a “work” provision). Thus, if you were to purchase a new disability insurance policy with a “work” provision, and your old disability insurance policy had a “no work” provision, one of the policies would be rendered useless (because it would be impossible to collect total disability benefits under both policies).
When purchasing a new disability insurance policy, it’s also important to keep in mind that disability policies have become increasingly more complex, restrictive and less favorable to policyholders over time. There is no longer a “standard” policy that every company sells—each policy will have it’s pros and cons, and it is therefore important to take your time to familiarize yourself with the disability insurance policy at the point of sale, so that you know what you’re purchasing. And if you didn’t pay close attention when you purchased the policy, or you can’t remember exactly what your policy says, you should review your disability insurance policy to assess whether it still meets your needs and make sure that you have an accurate understanding of the scope of your coverage.
Are There Options Besides A Trial When My Claim is Denied?
Reducing the risk of having to fight for disability benefits requires understanding the terms of your disability insurance policy from the beginning, carefully and thoroughly filling out the application, and ensuring accuracy and consistency in your claim packet and subsequent filings. As the saying goes, the best defense is a good offense, and the best way to avoid litigation is to file the disability claim correctly the first time.
Although filing a successful disability claim is not easy, it is the ideal. Unfortunately, insurance companies have a strong incentive to increase their bottom lines and often they practice aggressive tactics in improper attempts to justify the denial or termination of even a wholly legitimate disability claim. If your disability claim has been terminated or denied, it can seem overwhelming or hopeless to try to reverse the decision. In the event of a denial or termination, many insureds know they can sue their disability insurer and go to trial. Yet, even if you are ultimately successful in a lawsuit, litigation can sometimes drag on for years. While a lawsuit is pending, you’ll not only have legal expenses, but will also not be receiving disability benefits (and likely not be in a position to work to offset your expenses, due to the nature of your disability or your policy’s language). There are, however, some alternative options that can be attractive to both parties that policyholders may not be aware of, namely mediation and lump sum settlements.
Mediation
All too often we see legitimate disability claims denied or terminated, with the insurance company refusing to reconsider their position. If your disability claim is terminated, the company knows that it wields a lot of power over the denied individual, including the power of money, the power of time, the power of institutional knowledge, and the power to tolerate litigation. In other words, insurers calculate that spending money on even protracted litigation will end up being cheaper than continuing to pay disability benefits, and they know that many claimants will just give up and go away if they draw out court proceedings long enough.
While this might sound bleak, there can be alternatives to a full-fledged lawsuit that culminates in a trial (and potentially drawn-out appeals). One such method is mediation. Mediation is where the parties to a lawsuit meet with a neutral third party in an effort to settle the case.
For the most part, mediators are retired judges, or active or retired attorneys. The mediator reviews the case file and then meets with both parties, seeking to facilitate discussions between the parties and try to find common ground in order to reach an acceptable compromise. Because mediation is not binding, the mediator’s recommendation and any subsequent agreement between the parties is not final until the parties memorialize it by putting all the agreed upon terms in writing and signing the document.
Often the insurance company will offer to draft the agreement so they can have control over what the agreement says, and so it is important to stay engaged in the process even after the mediation has ended, in order to ensure that the parties’ agreement is accurately documented. The settlement agreement itself is a very important document, so you should be sure to take the time to carefully review it before signing, to be sure it encapsulates all the agreed upon terms.
It is also important to keep in mind that mediation typically does not result in a full restoration of disability benefits nor is not always successful. The non-binding nature of mediation means that if the insurance company low-balls and refuses to budge in its offer, the claimant may need to just walk away and resume litigation.
Lump Sum Settlement
Another way of avoiding trial is through negotiating a lump sum settlement. This typically occurs outside of the mediation setting, but sometimes requires the filing of a lawsuit before the insurance company is willing to come to the table. When this happens, your insurer agrees to buy out your disability insurance policy and you release your right to collect disability benefits under your policy and your insurer from any obligation to you. The buyout amount will be your disability insurance policy’s “present value” (i.e. the amount of money you could invest upon receipt, based on a determined interest rate, and end up with the same amount of money you would have received in disability benefits at the end of your policy), discounted by a percentage that is negotiated by the parties.
A buyout can be an attractive offer and can occur at any stage of the litigation process. A lump sum buyout could even be a preferable alternative to having disability benefits reinstated, as you would no longer have to deal with your insurer. Your disability benefit payments would cease being on hold pending the outcome of a trial and you could invest the lump sum in order to provide for your and your family’s future. In addition, unlike monthly disability benefits, the lump sum settlement you receive would be inheritable and available to be passed on to your heirs, should something happen to you.
There are, however, certain drawbacks to a lump sum buyout, including the fact that you and your disability insurers cannot accurately predict the future of the market with 100% certainty, so the calculations will only be a best estimate. If you are healthy and have lifetime benefits, you could also receive more money cumulatively over time if you were to stay on claim. So, while attractive, especially when faced with litigation, the pros and cons must be carefully weighted when considering lump sum buyouts during the litigation process.
We often see claimants who face the loss of their disability benefits simply give up and accept a denial, daunted by the thought of protracted litigation. While litigation may sometimes be the most advisable way to get benefits, and possibly punitive damages, there are other avenues to explore, advisably with the help of a disability insurance attorney, that can end in your retaining at least some of the disability benefits you stand to lose completely when an insurance company denies your disability claim.
Can A New Blood Test Objectively Prove Fibromyalgia?
As we’ve discussed in more detail in a previous post, fibromyalgia is a syndrome characterized by chronic, wide-spread muscle pain as well as fatigue, difficulty sleeping, depression or anxiety, muscle knots, cramping, or weakness, painful trigger points, and headaches. Fibromyalgia can be difficult to diagnose, given the relative or subjective nature of most symptoms. Symptoms can also mimic those of rheumatoid arthritis and other diseases, so often a diagnosis is established after other causes of symptoms are ruled out. Doctors will examine a patient’s history, conduct a physical examination, as well as evaluate X-rays and blood work. Doctors will also test patients for 18 tender points. The American College of Rheumatology guidelines suggest that those with fibromyalgia have pain in at least 11 of these tender points.[1]
Although the majority of fibromyalgia cases are diagnosed chiefly by ruling out other conditions, many patients may now have access to a blood test that may diagnose the disease. In 2012 a privately held biomedical company, EpicGenetics, released the FM/a® Test, which is an FDA-compliant blood test designed to diagnosis fibromyalgia. The test identifies the presence of certain white blood cell abnormalities.[2] The use and accessibility of the test has been growing, as Medicare and an increasing number of private insurance providers have begun covering the costs,[3] and the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) has also recently agreed to cover the cost of testing.[4]
The blood test works by analyzing protein molecules in the blood called chemokines and cytokines. Founder and CEO of EpicGenetics, Bruce Gillis, MD, explains that those with fibromyalgia have a lower count of these protein molecules in their blood, leading to weaker immune systems.[5] A diagnosis of fibromyalgia the traditional way can take, on average, more than two years.[6] Many believe that FM/a® offers an objective and concrete diagnosis that allows sufferers to more quickly find adequate resources and treatment.
However, others argue that the test does not offer the diagnosis it promises. Some argue that fibromyalgia is not a discrete medical condition but rather a “symptom cluster” or that the biomarkers the test identifies are also found in people with different illnesses, such rheumatoid arthritis.[7] As of this writing, major medical resource databases such as MedLine Plus, the CDC, and the Mayo Clinic continue to state that there is no lab test or definitive way to diagnose fibromyalgia.
As we’ve previously discussed, disability insurance policy holders can often face challenges with they go to file a claim based on disabilities, such as fibromyalgia, that are considered “subjective conditions.” A test promising objective proof may remove some of these challenges. However, it remains to be seen how insurance companies and the medical community as a whole will agree on what constitutes objective proof of fibromyalgia, whether via this test or other medical advances down the road.
[1] 18 Points Used to Diagnose Fibromyalgia, Health, http://www.health.com/health/gallery/0,,20345635,00.html#where-does-it-hurt–1
[2] Businesswire, EpicGenetics with the Assistance of Leading Medical Centers, Expands Clinical Study of FM/a® Test to Diagnose Fibromyalgia, Identify Genetic Markers Unique to the Disorder and Explore Direct Treatment Approaches, Yahoo! Finance, Apr. 19, 2017, https://finance.yahoo.com/news/epicgenetics-assistance-leading-medical-centers-120000519.html
[3] Pat Anson, Fibromyalgia Blood Test Gets Insurance, Pain News Network, May 27, 2015, https://www.painnewsnetwork.org/stories/2015/5/27/fibromyalgia-blood-test-gets-insurance-coverage
[4] Emily Riemer, Mass General researcher investigating possible fibromyalgia vaccine, WCVB5, July 27, 2017, 6:05 p.m., http://www.wcvb.com/article/mass-general-researcher-investigating-possible-fibromyalgia-vaccine/10364683
[5] Anson, id.
[6] Getting a Diagnosis, Fibrocenter, http://www.fibrocenter.com/pain
[7] Anson, id.
Myofascial Pain Syndrome
In previous posts, we have discussed the challenges attendant to chronic pain, including how dentists often experience pain due to the unnatural and static positions they must maintain for extended periods of time (which place stress on their musculoskeletal and muscular systems). This post will delve further into one such chronic pain condition, myofascial pain syndrome (MPS).
Overview
Myofascial pain syndrome is a chronic pain condition that affects the fascia (the connective tissues that spreads throughout the body). Specifically, myofascial pain syndrome refers to the pain and inflammation of muscles and soft tissue.
With someone suffering from myofascial pain syndrome, pressure on sensitive points in muscles (trigger points) can cause pain in seemingly unrelated parts of their body (called referred pain). A single muscle or a muscle group may be involved. Typically, the pain affects one side of the body only, or one side significantly more than the other. There may also be tenderness in areas not experiencing chronic pain.
Symptoms
While many people experience muscle pain or tension, those who suffer from myofascial pain syndrome experience persistent and worsening pain. Additional symptoms include:
- Deep and aching pain at specific trigger or tender points
- Spasms
- Tenderness
- A knot or clump in a muscle area
- Insomnia or sleep disturbances
- Fatigue
- Depression (which often co-occurs with MPS)
Causes
The pain and strain in a muscle caused by a trigger point associated with MPS can be attributed to numerous sources, including:
- Injury or prior injury
- Excessive strain or overuse of a muscle or muscle group
- Unnatural movements
- Repetitive motions
- Poor sleep schedules and sleeping positions
- Fatigue
- Certain medical conditions (e.g. heart attack)
- Lack of activity
- Stress or anxiety
Diagnosis
Because there are no visual indicators such as redness or swelling associated with MPS, doctors typically will perform a physical exam that includes applying pressure to the painful area. A doctor will feel for trigger points, which are divided into four types:
- Active – an area of extreme tenderness associated with local or regional pain.
- Latent – a dormant area that has the potential to act like a trigger point, and may be associated with numbness or restriction of movement.
- Secondary – a highly irritable spot in a muscle that may become active due to a trigger point, or if there is overload on another muscle.
- Satellite Myofascial Point – a highly irritable spot that becomes inactive because the muscle is in the region of another trigger point.
Although not as common, physicians may use Electromyography (EMG) to locate trigger points. In addition, doctors will usually conduct additional tests and procedures to rule out other causes of the muscle pain (e.g., lab tests to rule out vitamin deficiency).
Treatments:
Myofascial pain is treated using a variety of techniques, often in conjunction, such as:
- Medication (e.g. pain medications, medication for muscle spasm, antidepressants)
- Trigger point injections (which typically contain a local anesthetic or saline, sometimes with corticosteroid)
- Physical Therapy
- Spray and stretch (a treatment where a cooling agent is sprayed on the sore muscle, followed by gentle stretching)
- Massage Therapy
- Acupuncture
- Heat Therapy
- Ultrasound
- Posture and Stretching Training
Exercise, relaxation, and a healthy diet are also recommended techniques to help alleviate MPS pain.
These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.
References:
Mayo Clinic, http://www.mayoclinic.org/
WebMD, http://www.webmd.com/
Cleveland Clinic, clevelandclinic.org
MedicineNet, https://www.medicinenet.com/script/main/hp.asp
Chowdhury, Nayeema, OMS IV and Leonard Be. Goldstein, DDS, PhD, Diagnosis and Management Of Myofascial Pain Syndrome, Practical Pain Management, last updated March 19, 2012, https://www.practicalpainmanagement.com/pain/myofascial/diagnosis-management-myofascial-pain-syndrome.
Post-Traumatic Stress Disorder (PTSD)
In prior posts, we’ve examined how the demands of practicing render physicians and dentists uniquely susceptible to anxiety and depression. In this post, we are going to examine Post-Traumatic Stress Disorder (PTSD), another serious condition that often affects doctors—particularly doctors who work in high stress environments and who are repeatedly exposed to trauma on a daily basis.
What is PTSD?
PTSD is a mental health disorder caused by exposure to a shocking or dangerous event. Although most people who experience a traumatic event experience an immediate emotional response when they are experiencing the event, those who develop PTSD continue to experience the symptoms of exposure to trauma after the event, and feel stressed or panicked even when there is no danger. While some of the symptoms are similar to other anxiety disorders, PTSD is categorized as a particular type of anxiety that is caused by a specific external catalyst. The onset of PTSD can occur within months after a traumatic event; however, in some cases symptoms may not appear until years later.
Prevalence
PTSD is associated with those who have been exposed to a traumatic event, such as combat, violence, serious accidents, or natural disasters. Approximately seven to eight percent of the U.S. population will have PTSD at some point in their lives, with about eight million adults suffering from PTSD in any given year.[1]
PTSD can be caused by one event, or by prolonged exposure to trauma over time. This exposure can be experienced directly, and through indirect exposure (i.e. witnessing the event).[2]
Many physicians, depending on their specialty, interact on a daily basis with traumatic situations from early on in their careers, and sometimes encounter events where patients die or are seriously harmed in a way that is very distressing to a practitioner. Significantly, research has shown that 13 percent of medical residents meet the diagnostic criteria for PTSD.[3] Emergency physicians, physicians practicing in remote or under-served areas, and physicians in training (i.e. residents) are particularly prone to developing PTSD.[4]
The prevalence of PTSD is also substantially elevated in individuals who are also suffering from chronic pain. While only 3.5% of the general population has a current PTSD diagnosis, one study found that 35% of a sample of chronic pain patients had PTSD. Another study of patients with chronic back pain showed that 51% experienced significant PTSD symptoms. In instances where the chronic pain is caused by the traumatic event (e.g. someone involved in a motorcycle accident or someone injured during the course of a violent crime), the pain can serve as a reminder of the event and worsen the PTSD.[5]
Symptoms
Physicians who suffer from PTSD may lose this ability to confidently react, which can impair their ability to safely practice. Untreated, PTSD can also lead to a marked decline in quality of life, and potentially other mental health disorders or medical issues. Some common symptoms of PTSD include:
Re-experiencing symptoms:
- Flashbacks
- Nightmares
- Frightening thoughts
- Physical reactions or emotional distress after exposure to reminders
- Intrusive thoughts
Avoidance symptoms:
- Staying away from places, events, or objects that are reminders to the traumatic experience
- Avoiding thoughts or feelings related to the traumatic event
Arousal and reactivity symptoms:
- Being easily startled
- Feeling tense and “on edge”
- Having difficulty sleeping
- Being irritable or aggressive
- Heightened startle reaction
Cognition and mood symptoms:
- Trouble remembering key events of the traumatic event
- Negative thoughts about the world, and oneself
- Distorted feelings of guilt or blame
- Loss of interest in previously enjoyed activities
- Negative affect
Diagnosis
PTSD is typically diagnosed by a clinical psychiatrist or psychologist. A diagnosis is made when an individual meets the criteria for exposure, and has at least one re-experiencing symptom, one avoidance symptom, two arousal and reactivity symptoms, and two cognition and mood symptoms.
Treatments
Some of treatments that are used, either alone or in conjunction, to treat PTSD include;
- Cognitive Behavioral Therapy
- Eye Movement Desensitization and Reprocessing (EMDR)
- Prolonged Exposure Therapy
- Antidepressants
- Anti-anxiety medication
- Medication for insomnia
The intensity and duration of PTSD symptoms vary. Individuals who recognize any of the above-referenced symptoms in themselves should talk to a treatment provider right away.
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:
Medscape, http://emedicine.medscape.com
National Institute of Mental Health, https://www.nimh.nih.gov
WebMD, http://www/webmd.com/
[1] U.S. Department of Veterans Affairs, PTSD: National Center for PTSD, How Common Is PTSD?, https://www.ptsd.va.gov/public/ptsd-overview/basics/how-common-is-ptsd.asp
[2] U.S. Department of Veterans Affairs, PTSD: National Center for PTSD, PTSD and DSM-5, https://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp
[3] Myers, Michael, MD, PTSD in Physicians, Psych Congress Network, Sept. 16, 2015, https://www.psychcongress.com/blog/ptsd-physicians
[4] Lazarus, A., Traumatized by practice: PTSD in physicians, J Med. Pract. Manage., 2014 Sept-Oct; 30(2): 131-4.
[5] DeCarvalho, Lorie T., PhD, U.S. Department of Veterans Affairs, PTSD: National Center for PTSD, The Experience of Chronic Pain and PTSD: A Guide for Health Care Providers, https://www.ptsd.va.gov/professional/co-occurring/chronic-pain-ptsd-providers.asp
How Long Does It Take to Get Benefits? – Part 2
In an ideal world, you’d receive a favorable decision and your first benefit check shortly after your disability insurance policy’s elimination period is satisfied. Unfortunately, even wholly legitimate disability claims get scrutinized, questioned, delayed, and in some cases, denied. Below are a few common reasons disability benefit payments are delayed, particularly at the outset of a disability claim.
Improperly Completed/Partially Completed Forms
If your initial claim forms are missing information, unreadable, or incomplete, your disability insurer will likely issue additional forms for completion or use the missing information as an excuse to delay processing the disability claim. This applies to both the forms that you are required to complete and sign and the forms the insurer gives you to give to your doctor to fill out, so it is important to follow up with your doctor and make sure that all of the necessary forms are completed and returned in a timely fashion. If you do not carefully document your disability claim, and you do not promptly respond to requests for follow-up information, most insurers will delay making a claim decision until you provide them with the requested information.
Pending Requests for Information
At the outset of your disability insurance claim, your insurer will require you to sign an authorization that allows them to request a wide range of information from a wide range of sources, including your doctors and employer. Oftentimes, the insurer will request information from these other sources (without telling you) and then will delay making a decision on your disability claim if any of these requests remain pending.
This means that even if you provide the insurance company with everything they requested from you, there may be other information that the company is waiting that is holding up the claims decision. Consequently, it’s important to ask the insurance company to find out if there are any pending requests, adn then follow up with your doctors, employers, etc. as needed to ensure that the information is provided.
It’s also important to keep tabs on the pending requests, to determine whether the scope of the disability insurer’s investigation is appropriate. An experienced disability attorney can advise you on whether a particular request for information is warranted under the circumstances of your particular claim.
Failure to Schedule Medical Examinations/Interviews
When you file a disability claim, insurers will almost always require that you participate in a detailed interview and/or undergo an independent medical examination (IME). While the stated point of these requests is to confirm or verify your disability, they can often be an attempt by your insurer to discredit your own doctor or medical records and generate fodder to deny your disability claim. Depending on the nature of your condition, your disability insurer might also request other types of interviews or exams—such as a functional capacity evaluation (FCE) or neuropsychological evaluation.
Some claimants (mistakenly) believe that if they keep putting off these exams, then they’ll be able to avoid the exams. However, most disability policies contain a provision that expressly requires the policyholder to submit to exams, and states that failure to do so is grounds for denying a claim or terminating disability benefits. So if you put off these exams, it’s only going to delay the company’s claim decision, and possibly result in a claim denial. However, keep in mind that going into a medical examination, IME, or interview unprepared can be just as bad for your claim, so it’s very important to prepare beforehand. Once again, an experienced disability attorney can advise you regarding the proper scope of an interview or IME, and can also be present for the interview or IME, if desired.
How Long Does It Take to Get Benefits? – Part 1
You’ve made the difficult decision to give up practicing medicine or dentistry and file a disability claim. You’re not working and you need to collect the disability benefits you’ve likely paid years of high premiums for. So how long will you have to wait until your first benefit check arrives?
Unfortunately, the answer is not clear cut—it depends on the terms of your disability insurance policy, your insurance company, the assigned benefits analyst, and the complexity of your disability claim, among other things.
Filing a Claim
Your disability insurance policy should outline the requirements for filing a disability claim. Typically, you must give notice of your disability claim to your insurer within a certain time frame. If you miss this important deadline, the insurance company will typically claim that you have prejudiced its ability to investigate your claim, and use this as an excuse to delay making a decision on your disability claim. Significantly, if you don’t provide timely notice, it can also foreclose your ability to collect disability benefits (depending on the circumstances, and the reason for the delay).
Once you file your disability claim with your insurer, they will then send disability claim forms to be completed by you and your physician. Your policy should include a deadline for when your insurer must provide you with these forms (e.g. 15 days). If they don’t provide you with forms within this time frame, most disability insurance policies allow you to submit a written statement documenting your proof of loss, in lieu of the forms. Again, there is a deadline to return these forms and failing to do so gives your disability insurer an excuse to prolong the decision-making process.
Elimination and Accumulation Periods
Your disability insurance policy will also contain details about your elimination period. This is the period of time that must pass between your disability date and eligibility for payment on a disability claim. Generally, you must be disabled (as defined in your policy) and not working in your occupation during this time period.
Depending on the terms of your disability insurance policy, this period does not necessarily have to be consecutive, but it does need to occur within the accumulation period also set out in your policy (for example, your policy might require a 90 day elimination period that must be met within a 7 month accumulation period). You will not be eligible for payment until the elimination period has been fulfilled. Typically, disability insurers won’t provide you with a claim decision until after this date has passed.
It is important to be aware of your elimination period, so that you can plan accordingly (and are not expecting a benefit payment to arrive right way when you are budgeting to meet living expenses, or debts like student loans). Also, it’s important to keep in mind that receiving a benefit payment immediately following the elimination period is the ideal scenario. In many disability claims, it takes much longer for a benefit to be issued. In our next post, we will address some of the most common reasons disability benefit payments are delayed.
Policy Riders: Social Insurance Substitute Rider
In prior posts we’ve talked about riders and how they can modify the terms of a disability policy. In this post, we will be looking at a rider we sometimes see in individual disability policies called a Social Insurance Substitute rider.
A Social Insurance Substitute (SIS) rider is an optional rider that provides a monthly benefit that works a little differently than a standard base benefit. Generally speaking, SIS benefits can be reduced if you are eligible for and receiving social insurance benefits (e.g. Social Security retirement or disability benefits, workers’ compensation benefits, etc.).
SIS riders can operate differently, depending on the terms of your disability insurance policy. In some instances, the disability benefit paid by the insurer will be reduced by the amount received from social insurance (usually up to a certain amount). In other disability insurance policies, a certain percentage is subtracted from the benefits based on how many different forms of social insurance you are receiving (e.g. if you are receiving Social Security benefits, you might only receive two-thirds of your monthly benefit amount, and your monthly benefits might be further reduced if you started receiving benefits from a second source, like worker’s compensation).
The appeal of the SIS rider is that including it in a policy will typically result in a lower premium. The logic behind this is that the insurance company shares the risk of payment with the government. The primary downside to an SIS rider is the fact that your disability benefits will be reduced in some fashion if you obtain social insurance benefits.
In addition, policies with an SIS rider can also place additional requirements on policyholders by:
- Requiring policyholders to apply for social insurance benefits;
- Requiring policy holders to reimburse them if a lump sum payment is received from social insurance(s); and
- Requiring policyholders to go through the entire appeals process following any social insurance denials and/or re-apply for social insurance benefits periodically.
When choosing a disability insurance policy, it is important to weigh what you can afford in premiums now with potential future benefits. If you can afford a higher premium, it is often in your best interest to choose a disability insurance policy without an SIS rider and with a higher base benefit. As we have discussed previously, there are also certain riders that you can purchase that will automatically increase your monthly disability benefit (and premiums) by a certain amount each year and/or allow you to apply to increase your monthly benefit in the future, without undergoing additional medical underwriting. Whether you are shopping for a disability insurance policy, or evaluating your existing policy, you should always keep in mind that the cost of the premium is not the only consideration. There are other factors in play that you must consider when purchasing a disability insurance policy, and the type of insurance that you purchase can have a significant impact upon your financial position if you should become disabled.
Migraine Headaches
Migraine headaches can be debilitating, and, in some cases, chronic. In this post, we will look at some of the symptoms of migraines, how they are diagnosed, and some common treatments for migraines.
Overview
Migraines are characterized by severe headaches that usually involve throbbing pain felt on one side of the head, and can be accompanied by symptoms such as nausea, vomiting, and/or sensitivity to light and sound.
Migraines are the third most prevalent illness in the world, and can interfere with an individual’s ability to work and complete day-to-day activities, especially for those suffering from chronic migraines. Some studies have determined that healthcare and lost productivity costs associated with migraines may be as high as $36 billion annually. Migraines can affect anyone—in the U.S. 18% of migraine sufferers are women, 6% are men, and 10% are children. They are more common in individuals aged 25 to 55 and in those with family members that also suffer from migraines.[1]
Symptoms
Migraine symptoms, frequency, and length vary from person to person. However, they usually have four stages:
Prodrome: This occurs one or two days before a migraine attack and can include mood changes, food cravings, neck stiffness, frequent yawning, increased thirst and urination, and constipation.
Aura: This stage can occur before or during a migraine attack. Auras are usually visual disturbances (flashes of light, wavy or zigzag vision, seeing spots or other shapes, or vision loss. There can also be sensory (pins and needles, numbness or weakness on one side of the body, hearing noises), motor (jerking), or speech (difficulty speaking) disturbances. While auras often occur 10 to 15 minutes before a headache, they can occur anywhere from a day to a few minutes before a migraine attack. Typically, an aura goes away after the migraine attack, but in some cases, it lasts for a week or more afterwards (this is called persistent aura without infarction).
Migraine: The migraine itself consists of some or all of the following symptoms:
- Pain on one or both sides of the head that often begins as a dull pain but becomes throbbing
- Sensitivity to light, sound, odors, or sensations
- Nausea and vomiting
- Blurred vision
- Dizziness and/or fainting
- Migrainous stroke or migrainous infraction (in rare cases)
Post-drome: This stage follows a migraine and can include confusion, mental dullness, dizziness, neck pain, and the need for more sleep.
A migraine can last anywhere from a few hours to several days, and there are several classifications of migraines, including:
- Classic migraine – migraine with aura
- Common migraine – migraine without aura
- Chronic migraine – a headache occurring at least 15 days per month, for at least three months,
eight of which have features of a migraine - Status migraine – (status migrainosus) a severe migraine attack that lasts for longer than 3 days
Causes
The exact causes of migraines are not clearly understood but involve abnormal brain activity, including (1) changes in the brain stem and its interactions with the trigeminal nerve and (2) imbalances in brain chemicals, including serotonin. Migraines are most often triggered by:
- Food and food additives (often salty or aged food, MSG, meats with nitrites, aspartame)
- Skipping meals
- Drink (alcohol, caffeine, caffeine withdrawal)
- Sensory stimuli (bright or flashing lights, strong odors, loud noises)
- Hormonal changes or hormone medication such as birth control
- Certain other medications
- Stress or anxiety
- Strenuous exercise or other physical stress
- Change in sleep patterns
- Changes in weather
Co-occurrence
Migraines have been shown to co-occur with several other conditions[2], including:
- Cardiovascular disorders, coronary heart disease, and hypertension
- Stroke
- Psychiatric disorders (anxiety, depression, bipolar disorder)
- Restless leg syndrome
- Epilepsy
- Chronic pain such as musculoskeletal pain[3]
Treatment
There are a variety of options that doctors employ to both treat and prevent migraine attacks.
- Pain-relieving medications (both over the counter and prescription)
- Preventative medications (which can include antidepressants, blood pressure
medications, and seizure medications) - Botox
- Transcutaneous supraorbital nerve stimulation (t-SNS)
(a headband-like device with attached electrodes) - Acupuncture
- Biofeedback
- Massage therapy
- Cognitive behavioral therapy (CBT)
- Herbs, vitamins, and minerals
- Relaxation exercises
- Sticking to a sleep schedule
- Exercise
- Avoidance of known triggers
Doctors also sometimes recommend keeping a headache diary, similar to a pain journal, which can help you track the frequency of your migraines and may help identify triggers.
These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.
References:
Cedars-Sinai, https://www.cedars-sinai.edu
Healthline, www.healthline.com
Mayo Clinic, www.mayoclinic.org
MedlinePlus, www.medlineplus.gov
[1] Migraine Research Foundation, About Migraine, http://migraineresearchfoundation.org/about-migraine/migraine-facts/
[2] Wang, Shuu-Jiun, et. al., Comorbidities of Migraine, Frontiers in Neurology, Aug. 23, 2010, http://journal.frontiersin.org/article/10.3389/fneur.2010.00016/full
[3] Id. (citing Von Korff M., et. al., Chronic spinal pain and physical-mental comorbidity in the United States: results from the national comorbidity survey replication, Pain 113, 331-330 (2005).
Spine-Related Musculoskeletal Conditions – Part 7 – Myelopathy
In this series, we have been reviewing spine-related musculoskeletal conditions that are frequently seen in dentists and surgeons. In this post, we will be looking at myelopathy.
Myelopathy
Definition: Myelopathy is damage to the spinal cord caused either by a traumatic injury or a chronic musculoskeletal condition. The term myelopathy generally refers to damage to the spinal cord, but may be used in reference to a handful of specific conditions, including:
Cervical Spondylotic Myelopathy: This is by far the most common form of myelopathy and involves the compression of the spinal cord in the cervical spine (neck). We will discuss cervical spondylotic myelopathy further below.
Thoracic Myelopathy: This occurs in the middle region of the spine. Typically, the spine gets compressed due to bulging or herniated discs, bone spurs, or spinal trauma.
Lumbar Myelopathy: This is a rare condition because the spinal cord typically ends in the upper section of the lumbar spine; however, the if the spinal cord is low-lying or tethered, it can be affected by this condition.
Cervical Spondylotic Myelopathy
Overview: Cervical spondylotic myelopathy is damage to the spinal cord due to spinal degeneration, most commonly in the form of spinal osteoarthritis. As the spinal cord is compressed (spinal stenosis) due to inflammation and osteophytes, it can cause damage to the spinal cord and lead to an array of neurological symptoms.
Causes: As discussed above, the inflammation and bone spurs (osteophytes) common to spinal osteoarthritis can exert pressure on the spinal cord and cause damage. Bulging and herniated discs and thickened ligaments can also contribute to myelopathy. In rarer cases an acute, traumatic injury to the neck can result in myelopathy.
Symptoms: Numbness, weakness, and/or tingling in the hands or arms, loss of balance, stiffness in the legs, and urinary urgency.
Diagnosis: A CT scan with a Myelogram is used to reveal indentations in the spinal fluid sac. In this procedure an opaque dye is injected into the spinal canal prior to the CT scan to create contrast and provide images of the spinal canal. This is done in conjunction with an MRI, which provides imaging of the spinal cord and nerve roots, as well as the intervertebral discs and spinal ligaments.
Treatment: Surgery to decompress the spinal cord and prevent further damage is the most common treatment for cervical spondylotic myelopathy. The precise nature of the surgery varies and depends on the severity of the condition and its location.
These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.
References:
1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.
The Hartford Purchases Aetna’s Life And Disability Insurance Business for $1.45 Billion
Aetna has arranged to sell its group life and disability benefits to The Hartford for $1.45 billion dollars in cash. While group life and disability insurance were a small portion of Aetna’s business (about $2 million in premiums for 2016, compared to The Hartford’s $8.3 million in premiums at the end of the third quarter), this transaction will allow The Hartford the become second largest group life and disability insurer, behind MetLife. The Hartford will also obtain digital assets from Aetna, including absence, claims management, and data analytics systems, as well as a customer portal. And, following the sale, Aetna will offer The Hartford’s group life and disability products through Aetna’s sales force. The Hartford has also agreed to reinsure Aetna’s book of group life and disability insurance, on an indemnity basis.
While an Aetna press release states the two companies will work together to support their mutual customers, and the majority of Aetna’s 1,800 employees who support the acquired business will transfer to The Hartford, there are no details yet on how Aetna’s plans will be administered going forward, including for those already on claim.
The acquisition is expected to close in November 2017.
Sources:
Aetna, The Hartford Signs Agreement to Acquire Aetna’s U.S. Group Life and Disability Business, Oct. 23, 2017
The Hartford, The Hartford to Acquire Aetna’s U.S. Group Life and Disability Business, Special Presentation Webcast, Oct. 23, 2017
Japsen, Bruce, Aetna To Sell Group Life Business To Hartford for $1.4B, Oct. 23, 2017, 9:04 a.m.
Livingston, Shelby, Aetna to shed its life and disability insurance businesses for $1.5 billion, Modern Healthcare, Oct. 23, 2017
Otto, Nick, The Hartford to acquire Aetna’s life, disability business, Oct. 23, 2017, 2:39 p.m.,
Reuters, Hartford to buy Aetna US life and disability unit for $1.45 billion, CNBC, Oct. 23, 2017, 9:16 a.m.
Reuters, The Hartford to Buy Aetna Group Life, Disability Benefits Business for $1.45 Billion, Insurance Journal, Oct. 23, 2017
Spine-Related Musculoskeletal Conditions – Part 6 – Degenerative Disc Disease
In this series, we have been examining spine-related musculoskeletal conditions. In this post, we will be looking at degenerative disc disease.
Degenerative Disc Disease
Definition: Degenerative Disc Disease (DDD) is the breakdown in the size and cushioning of the intervertebral discs.
Overview: The name of the condition is actually somewhat of a misnomer – it is not actually a “disease”, but rather a condition that is characterized by the degeneration of the intervertebral discs over time. Over time, the pressure and wear of repetitive use can cause discs to lose some of their water content and volume, reducing their ability to cushion and insulate the vertebrae from one another.
Symptoms: The symptoms most commonly associated with DDD are chronic pain, weakness, numbness, and tingling in the extremities, and reduced flexibility in the spine. Not all people with intervertebral disc degeneration, however, experience pain or other symptoms. This is due to the fact that the degeneration of the discs, by itself, does not bring on the symptoms described above. However, as disc degeneration becomes more severe, it can lead to other conditions that bring on the symptoms people normally associate with DDD (e.g., pain, numbness and tingling, weakness, etc.). Some of the conditions commonly associated with DDD are spinal osteoarthritis, spinal stenosis, and foraminal stenosis.
Causes: Reduction in the size and cushioning of your discs is part of the normal process of aging, and magnetic resonance imaging (MRI) studies have shown that almost everyone over the age of 60 has degeneration of their intervertebral discs to some degree.[1] Not all people with disc degeneration have back pain or other symptoms – in fact, individuals with relatively mild disc degeneration may experience no symptoms whatsoever.
However, age is not the only factor in DDD. Deterioration of the intervertebral discs can be accelerated and exacerbated by other factors. The culprit in many severe cases of DDD is stress-related damage in the form of repetitive use, trauma, injury, poor posture, poor movement, and obesity. Among these, one of the most common factors is repetitive use. For example, the repetitive, static posture of a dentist during clinical procedures creates (1) compressive forces on the cervical discs due to neck flexion, and (2) compressive forces on the lumbar discs due to axial loading. When these compressive forces are applied year after year on a daily basis, the result can be an accelerated deterioration of the intervertebral discs.
Diagnosis: Diagnosis will generally begin with a physical exam in which the physician will perform a variety of tests to evaluate the patient’s strength and range of motion. If the physical tests indicate DDD, an MRI is typically ordered to measure the disc space and check for cartilage erosion.
Treatment: Because DDD can cause such a broad range of symptoms and subsequent conditions, the treatment options vary widely. Depending on the circumstances, treatment can range from conservative options such as physical therapy and anti-inflammatory medications to surgical intervention in the form of a discectomy, laminectomy, laminoplasty, or spinal fusion.
Our next and final post in this series will discuss myelopathy.
These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.
[1] Degenerative Disc Disease, Arthritis Foundation, http://www.arthritis.org/about-arthritis/types/degenerative-disc-disease/
References:
1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.
SEAK Inc.’s 14th Annual Non-Clinical Careers for Physicians Conference, Oct. 21-22, 2017
SEAK, Inc.’s 14th Annual Non-Clinical Careers for Physicians Conference will be held on October 21 -22, 2017 in Chicago, Illinois. The conference is intended for physicians looking to explore careers outside the clinical setting.
Many doctors and dentists find themselves unable to practice, whether due to a disability, fatigue, burnout, loss of opportunity, wanting more control over their schedule, hope of financial gain, or just the desire to try a different career path or become an entrepreneur. The 375+ attendees at the conference will range from interns and residents to veteran physicians in their 70s. The conference aims to show physicians that switching to a non-clinical career is an opportunity with financial potential, and “is in fact a step forward, not a step backwards.” Attendees at the conference will network, meet with employers and recruiters, attend workshops and presentations and participate in one-on-one mentoring with physicians who have successfully made the transition to non-clinical careers. Several of the presenters have not only moved out of the clinical practice, but are also experienced life coaches dedicated to guiding other physicians into new careers. Sessions discuss opportunities for physicians with insurance companies, medical device companies, the pharmaceutical industry, contract research organizations, healthcare IT and medical informatics companies, and in education as well as in the consulting, medical administration, patient safety/quality, medical writing, and entrepreneurial fields.
Returning speakers include Gretchen M. Bosack, MD, who has transitioned to the Chief Medical Director of the Securian Financial Group and is also an accomplished public speaker; Rishi Anand, MD, who transitioned to the director of the Electrophysiology Laboratory at Holy Cross Hospital in Ft. Lauderdale, Florida, as well as serving as a medical legal consultant and expert witness, and a successful real estate investor; and Savi Chadha, MD, MPH, a medical science liaison with Tardis Medical Consultancy. The opening speaker, Philippa Kennealy, MD, MPH, CPCC, PCC, is president of The Entrepreneurial MD and the Physician Odyssey Program, where she helps physicians further their non-clinical careers.
Subjective Conditions Limitation Provisions
In previous posts we’ve talked about mental health limitation provisions. In this post, we are going to discuss a similar type of provision: subjective symptom limitation provisions.
What are Subjective Symptom Conditions?
Insurance companies typically invoke subjective symptom limitation provisions when a claimant describes a disability or condition based upon self-reported symptoms, without producing objective medical evidence to back up the reported symptoms. This can occur in situations where there is no standard accepted medical test to confirm a diagnosis, or when tests do not return any confirming or conclusive results, or when a claimant has not properly developed his or her medical records and/or simply neglected to have objective testing done.
We most often see these types of limitations in ERISA policies, but they are becoming more and more common in individual policies. An example from an actual policy defines subjective symptoms as follows:
Some examples of conditions an insurance company might contend are encompassed by this provision include:
- Fibromyalgia
- Chronic Fatigue Syndrome
- Sleep Apnea
- Paresthesia/Dysesthesia
- Carpal Tunnel Syndrome
- Myofascial Pain Syndrome
- Lyme Disease
- Orthopedic Conditions
- Temporal Lobe Phenomenon
- Vertigo
- Migraine
- Tinnitus
- Irritable Bowel Syndrome
- Osteopathic and Rheumatoid Arthritis
- Generalized Pain
- Epstein-Barr Syndrome
- Valley Fever
Disability insurers also use these limitation provisions to argue that other conditions should be limited, even when there is some objective evidence. For example, a dentist suffering from a musculoskeletal condition might report to his or her doctor that he or she is experiencing neck pain, or lower back pain. The doctor might order an MRI, which might show that the dentist has some issues in his or her cervical or lumbar spine, but even with the MRI imaging, it can sometimes be difficult to pinpoint the precise cause of the symptoms that are being reported. Disability insurers know this and target these types of claims because, under a broad reading of the policy provision, they involve subjective reports of pain and the physical source of the pain cannot always be conclusively verified using tests.
Why is this provision important to know about?
These limitations typically cap disability benefits that will be paid out, generally at 12 to 24 months. After this mark has been reached, no additional disability benefits will be issued even if your symptoms continue and you cannot return to work. In other words, a disability insurance policy you thought would last for the maximum benefit period can end up being good for as little as a year.
Insurance companies want to avoid paying out disability claims and often construct policies in a manner that allows them to restrict or deny disability coverage. This can include hiding limitations at the end of a disability insurance policy or in a vaguely worded provision. It is not enough to simply look at a policy’s schedule page, because a limitation provision may actually be much broader limitation than you might think when you read “mental/nervous limitation” in your policy summary. Subjective condition limitation provisions are often combined with mental health and substance abuse limitation provisions, so it is easy for a policy holder to skip over this sort of provision when scanning through his or her policy, assuming that it only applies to mental health disorders or alcohol/addiction issues.
The Takeaway
When invoking these limitations, the insurance company is not denying that a claimant has an illness or even that it prevents a policyholder from working. Rather, the insurance company is seeking to take advantage of the limits of medical science and/or lack of agreement in the medical community regarding finding and establishing guidelines regarding conditions like the examples listed above. They then use the subjective condition provision to cast doubt on a claim and complicate the claim procedure. Often, they will use multiple in-house physicians to contradict a claimant’s own physician and medical records.
Fighting an insurance company’s decision to classify a condition as subject to this provision can be a costly and long process, and can turn into an expensive war of attrition that can often end in litigation. For these reasons, these types of claims must be handled with care from the start and require the assistance of a supportive doctor to properly document and treat the condition.
When purchasing a disability insurance policy, it is important to watch out for subjective symptom condition limitation provisions. Always be sure to read your disability insurance policy or potential policy carefully so that you understand the scope of the your protection.
Spine-Related Musculoskeletal Conditions – Part 5 – Disc Bulge, Disc Herniation, and Disc Protrusion
Our posts in this series have been reviewing spine-related musculoskeletal conditions that are frequently seen in dentists and surgeons. In this post, we will be looking at disc bulge, disc herniation, and disc protrusion.
Disc Bulge, Disc Herniation, and Disc Protrusion
Definitions:
- Disc Bulge: Protrusion of a spinal disc outside the vertebral body that has not fully ruptured through the disc membrane, known as the annulus.
- Disc Herniation: Protrusion of a spinal disc outside the vertebral body that has ruptured through the annulus, exposing a portion of the nucleus – the gel-like center of the disc.
- Disc Protrusion: A general term to describe any type of disc bulge or herniation, in which a portion of the disc protrudes beyond the vertebral body.
Overview: A number of terms are used to describe spinal disc pathology and the associated symptoms. To complicate matters further, there is not a clear consensus among medical professionals about the precise meaning of each term.
There are thirty-three vertebrae in the vertebral column of the human spine, twenty-four of which articulate and move. Between each of the vertebrae in the three articulating sections of the spine – the cervical, thoracic, and lumbar spine – there is an intervertebral disc. Each disc, composed of soft jelly-like center (nucleus) surrounded by a capsule of connective tissue (annulus), provides shock absorption and flexibility within the spine. When the protrusion puts pressure on the spinal cord or a nerve root, it can lead to a wide range of symptoms.
Symptoms: Symptoms will vary based on the location of the disc:
- Lumbar: Pain radiating down the leg (sciatica) is the most common symptom associated with a lumbar disc herniation. Weakness in the foot and difficulty when raising the big toe (foot drop) and numbness/pain on the top of the foot are also prevalent.
- Cervical: Pain, weakness, numbness, and tingling in the shoulder, arm, or hand depending on the location of the herniated disc.
Causes: Disc bulges are often the result of the normal process of aging, and by themselves may not cause any recognizable symptoms. Bad posture associated with frequent sitting or standing and occupational hazards such as repetitive bending or standing can accelerate the formation of disc bulges.
Disc herniation is often a progression in severity from a disc bulge. As discs wear down over time, they may degenerate and lose some of their water content. This condition, known as Degenerative Disc Disease, is discussed in greater detail below. As discs degenerate and degrade, they become more flexible and the annulus may be more susceptible to tearing or rupturing. Disc herniation can also be caused by traumatic, acute injuries such as a hard fall or blow to the back.
Diagnosis: Diagnosis of a herniated or bulging disc typically begins with a physical exam that tests the patient’s reflexes, muscle strength, walking ability, and sensory perception (light touches, pin pricks, etc.). If a protrusion is indicated by the physical test, imaging may be ordered in the form of X-rays, MRIs, CT scans, and/or Myelograms.
Treatment: Non-invasive treatment may include heat therapy, exercise, physical therapy, chiropractic treatment, therapeutic ultrasound, and medication. Epidural steroid injections may be considered as an intermediate treatment. For more severe cases, a microdiscectomy may be performed, typically in an outpatient setting. In this procedure, a small portion of bone and/or disc material is removed to relieve pressure on the affected nerve root.
Our next post will discuss degenerative disc disease.
These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.
References:
1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.
Spine-Related Musculoskeletal Conditions – Part 4 – Spondylolisthesis
In this series of blog posts, we have been reviewing spine-related musculoskeletal conditions. The next condition we will be looking at is spondylolisthesis.
Spondylolisthesis
Definition: Occurs when a vertebra (typically in the lumbar spine) slides forward over the vertebra beneath it.
Overview: The vertebrae in the spinal column are linked together by small joints (facets) that permit the spine to bend forward (flexion) and backward (extension) while limiting rotational movement. Spondylolisthesis occurs when a joint defect in the vertebrae (resulting from either a stress fracture or degeneration) permits one vertebra to slip forward on the one beneath it.
Spondylolisthesis is most common in the lower back, though in rare cases it can occur in the cervical spine. It most frequently occurs at the L4-L5 and L3-L4 levels of the lumbar spine.
There are two types of spondylolisthesis: isthmic spondylolisthesis (IS) and degenerative spondylolisthesis (DS). IS occurs when a stress fracture of a small bone called the pars interarticularis permits a vertebra to slip forward over the vertebra below it. IS is rare, and is most common in young children who participate in sports that put repeated stress on the lower back.
DS is far more common and most regularly occurs among people over the age of 50. DS is a result of the gradual breakdown of the intervertebral discs and the facet joints in the spine. As the discs lose volume, more stress and pressure is placed on the facet joints. As the facet joints begin to degrade under the increased wear and pressure, they may allow too much flexion and cause a vertebra to slip forward over the vertebral body below it.
The slippage can place direct pressure on the spinal cord (spinal stenosis) and on the nerve roots exiting the spinal column (foraminal stenosis).
Symptoms: Lower back pain, leg pain (especially “running down” the leg), and sciatic pain are common. Numbness or weakness often occurs in one or both legs. Leg/back pain that is worse when bending over or twisting is common, as is pain that is worse standing than sitting.
Causes: Degenerative disc disease is a common cause of spondylolisthesis. As we discussed above, when the intervertebral discs lose volume the spinal column becomes more compressed. Without the shock absorption of the discs, more pressure is exerted on the facet joints. This pressure and wear accelerates the degradation of the facets and allows for the increased flexion in the spine that can lead to vertebral slippage. As clinical dentistry has moved from a standing profession to a seated one, dentists are at a higher risk for lower back conditions like spondylolisthesis. Axial loading (the weight of the body compressing the spine vertically) on the lumbar spine is significantly higher in a seated position than it is standing.
Diagnosis: X-rays are used to determine whether or not a vertebra is out of place. If the displaced vertebra is putting pressure on the spinal cord or nerve roots, a CT scan may be ordered to identify the severity of the problem.
Treatment: As with many other conditions discussed in this series, conservative treatment may include some combination of physical therapy, exercise, strength training, manual manipulation, and medication. Epidural steroid injections are sometimes prescribed for those in severe pain. Spinal fusion surgery is sometimes used for severe pain that has not been successfully treated with less invasive treatment. Typically, a posterior fusion with a pedicle screw implementation is used, but a surgeon may also recommend a spinal fusion done from the font of the spine simultaneously.
Our next post in the series will examine disc bulge, disc herniation, and disc protrusion.
These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.
References:
1. Spine-health, https://www.spine-health.com/.
2. Mayo Clinic, http://www.mayoclinic.org/.
3. The Neurological Institute of New York,
http://columbianeurology.org/about-us/neurological-institute-new-york.
4. John Hopkins Medicine, http://www.hopkinsmedicine.org/.
5. WebMD, http://www.webmd.com/.
What is a Neuropsychological Evaluation? – Part 4
This is the last post in our series of posts about neuropsychological evaluations. We will conclude this series by discussing (1) why an insurance company would ask for an exam, and (2) how a neuropsychological evaluation can impact your disability claim.
Why Would My Insurer Ask for a Neuropsychological Evaluation?
Unfortunately, it is way too common for an insurer to look for ways to deny a disability claim, even in the face of strong medical proof of a disability. This can be especially true for conditions or disabilities that are more subjective than objective, or disabilities that include symptoms that cannot be definitely shown by commonly administered medical tests. An insurer intent on denying a disability claim may use Independent Medical Evaluations (IMEs), Functional Capacity Examinations (FCEs), Neuropsychological Evaluations, or a combination of these three exams, in its efforts to undercut a policyholder’s own doctor’s evaluation and medical records (particularly if the policyholder’s treating doctor is supportive of the claim and has clearly indicated that the policyholder should not return to work in their own occupation).
As we discussed previously, the limitations inherent in neuropsychological evaluations may lead to a conclusion that you are less cognitively impaired than you truly are, and/or a recommendation that you are able to return to work. Further, if the test is administered by a biased evaluator, results can be interpreted and manipulated in order to deny your disability claim.
What Can I Do?
First, make sure that your insurance company can actually require a neuropsychological examination under the terms of your disability insurance policy. Some policies include provisions requiring that claimants undergo “medical exams” or exams “conducted by a physician.” If your policy contained this sort of provision, you could potentially argue that the insurance company cannot require you to undergo a neuropsychological evaluation, since a neuropsychologist is not a physician, and this sort of exam is not strictly a “medical exam.”
If you must undergo the evaluation, there are several steps you can proactively take to prevent the examination from unfairly complicating or jeopardizing your disability claim, many of which are similar to steps you should take before an IME.
- Be sure to provide complete medical records.
- Carefully fill out any intake paperwork.
- Advise your medical team of the request for the evaluation.
- Take notes, including what questions were asked during the interview portion of the evaluation.
- Report back to your medical team after the test, especially regarding any negative effects, such as increased fatigue after the evaluation.
- Request a copy of the report.
It is important to note that neuropsychological evaluations are not inherently biased or a poor indicator of disability. In fact, they can actually be helpful in confirming your disability and demonstrate an impaired level of functioning that makes it impossible to return to work. In some instances, you may wish to undergo an exam with a truly independent examiner, either proactively or as a follow up to one ordered by your insurer. As with any new evaluation or course of treatment, you should carefully discuss this option with your current medical team and attorney, and obtain recommendations to a reputable evaluator.
Sources:
Atif B. Malike, MD; Chief Editor, et al., Neuropsychological Evaluation, Medscape, http://emedicine.medscape.com/article/317596-overview, updated May 18, 2017.
Neuropsychological Evaluation FAQ, University of North Carolina School of Medicine Department of Neurology, https://www.med.unc.edu/neurology/divisions/movement-disorders/npsycheval
Kathryn Wilder Schaaf, PhD, et al, Frequently Asked Questions About Neuropsychological Evaluation, Virginia Commonwealth University Department of Physical Medicine and Rehabilitation, https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwir3pKk__fUAhUBEmMKHenkDzsQFggoMAA&url=http%3A%2F%2Fwww.tbinrc.com%2FWebsites%2Ftbinrcnew%2Fimages%2FNeuropsych_FAQ.pdf&usg=AFQjCNG0Mv3o17ZrNmXuDN5ITUIh4fWYtA&cad=rja
