What is a Neuropsychological Evaluation? – Part 3
Our previous posts in this serious have examined what a neuropsychological evaluation is and how these exams are conducted. In this post we’ll be talking about some of the limitations associated with these types of exams.
How Reliable Are Neuropsychological Evaluations?
As we explained in previous posts, neuropsychological evaluations seek to provide information about the brain and behavior through the use of established, standardized tests that produce quantitative data. This data can then be used to confirm and back up a subject’s reports of cognitive impairment.
These evaluations can serve several purposes, such as corroborating the cognitive effects of a disability, or outlining a subject’s limitations in his or her daily life (including the inability to return to one’s own occupation). For example, an evaluation might show that a dentist with a head injury has impaired motor skills and visuospatial processing abilities that make it unsafe for the dentist to continue treating patients. In this sense, an evaluation can provide data that can lend further support to a disability claim, but wouldn’t necessarily show up on an MRI or the results from other types of medical testing.
However, while these evaluations can be useful, they also have certain limitations that are important to consider. As with Functional Capacity Evaluations (FCEs) the examination is truly just a snapshot—the data is based on your functioning on a specific day, for a limited amount of time, in a quiet and controlled testing room.
Generally, findings indicate that performance on tests of motor function, speed of cognitive processing, cognitive flexibility, complex attention, and memory are related positively to real-word success. However, some argue that these exams do not adequately take into account the fact that, in the real world, several executive functions (such as recognizing a task must be completed, starting a task, switching tasks, making needed changes, finishing a task, etc.) can occur simultaneously. Further, the administered test may not indicate whether a subject was mentally exhausted after the test,[1] and thus may not provide any insight into whether the subject is able to sustain the same demonstrated level of executive functioning day in and day out.
While the administered tests are designed to be objective and produce results that can be extrapolated across populations, this is not always possible. While a subject’s results should be compared with both population-based norms as well as specific patient populations for strengths and weaknesses, there can be gaps in normative data for certain age, educational, and intellectual ranges.[2] This can be especially true for minority populations.[3] Along these same lines, an evaluator may not take into account norms specific to doctors, or a doctor’s need for higher performance on certain tests (e.g. those for sensory-perceptual functions), when assessing whether a return to work is possible.
Excessive fatigue, medications, lack of motivation (sometimes due to depression), emotional distress, severe psychiatric conditions, serious medical complications, and illicit substances can also all impact the reliability of an evaluation.
Additionally, as we’ve discussed before in the context of Independent Medical Examinations (IMEs), a neuropsychological examiner selected by an insurance company may be presented as independent, but may not truly be so. An examiner selected and paid for by a disability insurer may be more likely to report that a subject is “malingering,” trying to influence a test’s outcome, or not putting forth a true effort.
In our next post, we will further explain why an insurer might require a neuropsychological evaluation, and how these exams can impact a disability claim.
[1] Atif B. Malike, MD; Chief Editor, et al., Neuropsychological Evaluation, Medscape, http://emedicine.medscape.com/article/317596-overview, updated May 18, 2017.
[2] Id.
[3] Id. (citing Decker SL, Schneider WJ, Hale JB, Estimating Rates of Impairment in Neuropsychological Test Batters: A Comparison of Quantitative Models, Arch. Clin. Neuropsychol. 2011 Dec 15 [Medline].
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
Spine-Related Musculoskeletal Conditions – Part 3 – Stenosis
In this series, we have been looking at spine-related musculoskeletal conditions that many dentists and surgeons suffer from. In this post, we will be looking at spinal and foraminal stenosis.
Cervical Spinal Stenosis:
Definition: The narrowing of the spinal canal in the cervical vertebrae, often due to inflammation of the surrounding cartilage and tissue.
Overview: The spinal canal is formed by the hollow spaces in the middle of the vertebrae, which form a protective tunnel for the spinal cord to pass through the spinal column. Cervical spinal stenosis is a progressive and potentially dangerous condition that occurs when inflammation narrows the cervical spinal canal. The narrowing of this already tight space can result in direct pressure on the spinal cord, leading to a number of neurological complications. Cervical spinal stenosis can be crippling if the spinal cord becomes damaged.
Symptoms: Symptoms usually develop gradually over time and can include numbness, weakness, tingling in neck, shoulders, arms, hands, or legs, as well as intermittent, sharp pain in the arms and legs, especially when bending forward. Deterioration of fine motor skills and issues with gait and balance can also occur. In more severe cases, bladder and bowel issues may develop.
Causes: Though in rare cases cervical spinal stenosis is a congenital condition, it often results from inflammation due to other spinal conditions, such as spinal osteoarthritis, degenerative disc disease, and disc bulging.
Diagnosis: A combination of X-ray, MRI, and computed tomography (CT) scans may be used to diagnose spinal stenosis. Blood tests may be used to eliminate other diseases such as multiple sclerosis and vitamin B12 deficiency.
Treatment: Conservative, non-invasive treatments may include exercise, physical therapy, and activity modification. Medications may include anti-inflammatory drugs, narcotic pain medication, muscle relaxers, and epidural steroid injections. In more severe cases, several surgical options exist, dependent upon the particular characteristics of the patient’s condition:
Anterior cervical discectomy/corpectomy with fusion (ADCF): The spine is accessed through the front of the patient’s neck, the disc is removed from between the two vertebrae, and the vertebrae are then fused together to stabilize the spine.
Laminectomy: This is a “decompression” surgical procedure performed to relieve pressure on the spinal cord. In this surgery, the lamina (the rear portion of the vertebra covering the spinal canal) is removed from the affected vertebra to enlarge the spinal canal and decrease pressure on the spinal cord.
Interspinous Process Spacers: In this procedure, small metal spacers are surgically placed between the vertebrae to restore the spacing typically created by a healthy disc. This procedure is typically reserved for individuals with foraminal stenosis, however, and has only had limited effectiveness with patients suffering from spinal stenosis.
Foraminal Stenosis
Definition: Compression of the nerve roots connected to the spinal cord, caused by the narrowing of the passageway through which the nerves exit the spinal column.
Overview: The nerve roots branching off the spinal cord to other parts of the body exit the spinal column through small openings on the sides of the vertebrae called a foramen. This space can become clogged or narrowed due to a number of spine-related conditions. The narrowing or partial obstruction of the foraminal canal caused by one of these conditions can put pressure on the nerve roots emerging from the spinal column, and may lead to an array of neurological symptoms that get progressively worse over time.
Symptoms: Tingling, numbness, or weakness in the feet or hands. Local pain in the extremities. “Pins and needles” or burning sensation. Intermittent neck or back pain.
Causes: Bulging or herniated discs may obstruct the foraminal canal, putting pressure on the nerve roots. It can also be caused by spinal osteoarthritis, osteophytes, and spondylolisthesis. Dentists are susceptible to foraminal stenosis, as they often hold their necks in extended positions.
Diagnosis: A CT scan and a Myelogram are used to diagnose foraminal stenosis. A Myelogram is an X-ray in which an opaque dye (which shows up on the X-ray) is injected into the sac around the nerve roots. The dye moves through the foramina, allowing the doctor to see the degree to which the foramen is narrowed or obstructed.
Treatments: Conservative treatments may include physical therapy, stretching and strength training, and oral pain-relieving medication. Corticosteroid injections are an option for more severe cases to reduce inflammation and pain. In extreme cases, a surgical procedure known as a foraminotomy may be used to remove the bone spur or disc material that is putting pressure on the nerve root as it exits the spinal column through the foramen.
Our next post in this series will discuss spondylolisthesis.
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 2 – Spinal Osteoarthritis
In the first part of this series, we discussed the fact that dentists and surgeons often suffer from musculoskeletal conditions. In the remaining posts in this series, we will be looking at particular musculoskeletal conditions, starting with spinal osteoarthritis.
Spinal Osteoarthritis
Definition: Spinal osteoarthritis is also known as degenerative joint disease. It is a breakdown of the cartilage in the facet joints, which link together the spine’s vertebrae.
Overview: At the top and bottom of each vertebra is a small pair of joints called facets. Facets connect the vertebrae in order to restrict movement in certain directions and to allow the spine to move as one fluid unit. The surfaces of the facets, like any other joint in the human body, are covered by a lubricating cartilage which allows them to operate smoothly and with little friction.
When the cartilage protecting the facets degrades or wears down, the bony surfaces of the facets rub against each other. This can cause inflammation, severe pain, and the formation of osteophytes (bone spurs) on or around the joint surfaces. It may also cause numbness and/or weakness in the legs and arms as a result of contact between the vertebrae and the nerves leaving the spinal cord.
Symptoms: Neck pain and stiffness. Severe pain may radiate down into shoulders and up the neck. Weakness, numbness, or tingling in the fingers, hands, and/or arms are also often present. Usually back discomfort is relieved when a person is lying down. Studies have also linked anxiety and depression to osteoarthritis.[1]
Causes: Spinal osteoarthritis frequently occurs in conjunction with degenerative disc disease. As the discs between the vertebrae in the spinal column degrade and decrease in volume, the increased pressure and contact between the facet joints can cause an accelerated degradation of the joint cartilage.
Repetitive strain or stress on the spine, often due to poor posture, to is a common cause of spinal osteoarthritis. People with jobs requiring repetitive movements and strained positions are considered to be at greater risk for conditions like spinal osteoarthritis; however, injury or trauma to a joint or a genetic defect involving cartilage are also causes. Dentists are at a higher risk than many other professions to develop this condition due to the awkward, static postures they must maintain.
Diagnosis: X-rays may be used to identify loss of cartilage, bone spurs, and bone damage. Magnetic resonance imaging (MRI) may be used to analyze the intervertebral discs and the nerves exiting the spinal column.
Treatment: Conservative, non-invasive treatment plans may include some combination of heat/cold therapy, medication, physical therapy, strength training, and stretching. In more severe cases, a surgical treatment such as spinal fusion is utilized.
Our next post in this series will examine spinal stenosis, another common cause of neck and back 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.
[1] Sharma, A., et. al, Anxiety and depression in patients with osteoarthritis: impact and management challenges, Open Access Rheumatology: Research and Reviews 2016:8 (2016).
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 2
In our last post, we looked at what a neuropsychological evaluation is, and how it can be used as a tool to identify cognitive impairments. In this post we will talking about how a neuropsychological evaluation works in more detail.
What Can I Expect During a Neuropsychological Evaluation?
A neuropsychological evaluation will generally consist of (1) a review of your medical and other records (this could include your disability insurance claim file); (2) an interview with you and sometimes another person such as a family member or caregiver who knows you well, (especially if your disability impacts your ability to self-report); and (3) the administration of tests that measure both your mood and abilities.
The evaluation will typically begin with an interview and then proceed to testing. The tests will be both written and oral, and vary in length and complexity. Often the tests will be administered by a specially trained technician, or a psychometrist. The typical evaluation takes between two to five hours to complete, but can stretch up to eight hours and/or be split into two sessions. Conditions such as fatigue or motor impairments can slow down the process.
The results will generally be presented in a report that includes a summary of the tests conducted, a summary of your key medical and personal history, your current issues (i.e. the reason the neuropsychological exam was requested), the results of the testing, how these results compare to other people with your background, and a list of recommendations. As explained previously, these recommendations can help indicate the need for additional treatment, suggest treatment options, and/or provide information on cognitive deficiencies and resulting physical and mental limitations.
The evaluation is designed to assess your knowledge, functioning, and skills at the time of the exam. Because of this, it is not the sort of test that you would “study” for, in the same sense that you would study for, say, an academic exam. However, if you are going to be undergoing a neuropsychological exam, evaluators typically recommend that you:
insert
- Get a good night’s sleep
- Put forth your best effort
- Provide a list of all medications and take all medication as normally scheduled, unless instructed otherwise
- Bring a friend or family member if you have trouble relating information about your history (for the interview portion of the examination)
- Make sure the evaluator has access to your medical records
- Do not consume alcohol or other illicit substances within the 24 hours prior to the evaluation
- Notify the examiner of excessive fatigue, psychological distress, or frequent changes in your ability to move
Our next posts in this series will address the reliability of neuropsychological examinations and why your disability insurance company may ask for one.
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
What is a Neuropsychological Evaluation? – Part 1
We’ve talked before about how your insurance company may require you to undergo an independent medical examination (IME) by a physician of their choosing and how they may also ask for a Functional Capacity Evaluation (FCE).
Neuropsychological evaluations are another tool insurers utilize when investigating disability claims. A neuropsychological evaluation is also something that a claimant filing a disability claim may choose to undergo independently, to provide additional proof of his or her disability. In this series of posts, we will be talking about what a neuropsychological evaluation is, what to expect during an examination, and how an exam could affect your disability claim.
What is a Neuropsychological Evaluation?
Neuropsychology is the study of the relationship between the brain and behavior. A neuropsychological evaluation is a method of testing where a neuropsychologist seeks to obtain data about a subject’s cognitive, behavioral, linguistic, motor, and executive functioning in order to identify changes that are, often, the result of a disease or injury. The evaluation can lead to the diagnosis of a cognitive deficit or the confirmation of a diagnosis, as well as provide differential diagnoses.
Neuropsychological evaluations are most often associated with conditions that exhibit cognitive dysfunctions, such as:
- Multiple sclerosis
- Alzheimer’s
- Epilepsy or seizures
- Psychological and mental health disorders
- Chronic pain
- Head injuries
- Stroke
- Parkinson’s disease
- Neurodegenerative diseases
- Side effects of medication
Conditions such as those enumerated above often have symptoms that vary person by person, and the amount of cognitive impairment can often not be fully assessed by other diagnostic tools such as an MRI, or a traditional psychological evaluation.
Neuropsychological tests are standardized tests that are given and scored in a similar manner each time they are used. The tests are designed to evaluate the following:
- Intellectual Functioning
- Academic Achievement
- Language Processing
- Visuospatial Processing
- Attention/Concentration
- Verbal Learning and Memory
- Executive Functions
- Speed of Processing
- Sensory-Perceptual Functions
- Motor Speed and Strength
- Motivation
- Personality
There are many different accepted tests for each domain listed above. Accordingly, an examiner will likely not perform every test, but rather select tests from each category that will best evaluate the particular question posed by the referrer.
The goal of these neuropsychological tests is to produce raw data. The results are then evaluated by comparing test scores to healthy individuals of a similar background (age, education, gender, ethnic background, etc.) and to expected levels of cognitive functioning. The data is then interpreted by the neuropsychologist, and perhaps other providers, to determine the strengths and weaknesses of the subject’s brain, provide suggestions for potential treatment options, set a standard for any future testing, evaluate a course of treatment, make recommendations on steps and modifications that can improve daily living, and evaluate whether a subject can return to work with or without modifications.
In our next post we will go look at what you can expect during a neurospychological evaluation.
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.
What is a Neuropsychological Evaluation? – Part 1
We’ve talked before about how your insurance company may require you to undergo an independent medical examination (IME) by a physician of their choosing and how they may also ask for a Functional Capacity Evaluation (FCE).
Neuropsychological evaluations are another tool insurers utilize when investigating disability claims. A neuropsychological evaluation is also something that a claimant filing a disability claim may choose to undergo independently, to provide additional proof of his or her disability. In this series of posts, we will be talking about what a neuropsychological evaluation is, what to expect during an examination, and how an exam could affect your disability claim.
What is a Neuropsychological Evaluation?
Neuropsychology is the study of the relationship between the brain and behavior. A neuropsychological evaluation is a method of testing where a neuropsychologist seeks to obtain data about a subject’s cognitive, behavioral, linguistic, motor, and executive functioning in order to identify changes that are, often, the result of a disease or injury. The evaluation can lead to the diagnosis of a cognitive deficit or the confirmation of a diagnosis, as well as provide differential diagnoses.
Neuropsychological evaluations are most often associated with conditions that exhibit cognitive dysfunctions, such as:
- Multiple sclerosis
- Alzheimer’s
- Epilepsy or seizures
- Psychological and mental health disorders
- Chronic pain
- Head injuries
- Stroke
- Parkinson’s disease
- Neurodegenerative diseases
- Side effects of medication
Conditions such as those enumerated above often have symptoms that vary person by person, and the amount of cognitive impairment can often not be fully assessed by other diagnostic tools such as an MRI, or a traditional psychological evaluation.
Neuropsychological tests are standardized tests that are given and scored in a similar manner each time they are used. The tests are designed to evaluate the following:
insert
- Intellectual Functioning
- Academic Achievement
- Language Processing
- Visuospatial Processing
- Attention/Concentration
- Verbal Learning and Memory
- Executive Functions
- Speed of Processing
- Sensory-Perceptual Functions
- Motor Speed and Strength
- Motivation
- Personality
There are many different accepted tests for each domain listed above. Accordingly, an examiner will likely not perform every test, but rather select tests from each category that will best evaluate the particular question posed by the referrer.
The goal of these neuropsychological tests is to produce raw data. The results are then evaluated by comparing test scores to healthy individuals of a similar background (age, education, gender, ethnic background, etc.) and to expected levels of cognitive functioning. The data is then interpreted by the neuropsychologist, and perhaps other providers, to determine the strengths and weaknesses of the subject’s brain, provide suggestions for potential treatment options, set a standard for any future testing, evaluate a course of treatment, make recommendations on steps and modifications that can improve daily living, and evaluate whether a subject can return to work with or without modifications.
In our next post we will go look at what you can expect during a neurospychological evaluation.
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.
Spine-Related Musculoskeletal Conditions – Part 1 – Spondylosis
Living with a spine-related condition can be scary and overwhelming. Unfortunately, the complex nature of the spine and the nervous system can often make the search for answers a frustrating and demoralizing endeavor. In this series of posts we are going to talk about several spine-related musculoskeletal conditions, many of which are frequently diagnosed in dentists, surgeons, and other physicians.
If you are suffering from a spine-related condition, you have likely visited not only your primary care physician, but also a physical therapist, a chiropractor, a neurologist, an orthopedic surgeon, and/or a pain management doctor. It’s common for those suffering from a musculoskeletal condition to hear several different terms to describe a set of symptoms, be given multiple explanations for what is causing their pain, and be given a variety of (often conflicting) treatment recommendations.
Dentists and physicians in certain surgical specialties are particularly susceptible to spine-related musculoskeletal conditions, which are among the top reasons insureds file disability claims. The forward-flexed, static posture that dentists and surgeons must maintain to perform procedures can lead to the overuse and repetitive strain of the neck and back, and contribute to the development of a litany of musculoskeletal conditions. One study showed that 62% of the general population present musculoskeletal work-related pain, and this increased to 93% when the sample population was made up entirely of dentists.[1] Unfortunately, although one often thinks of spinal and back injuries occurring later in life after years of strain, chronic musculoskeletal pain is experienced by many dentists by their third year of dental school.[2]
We’ve created this series of blog posts as a resource to help clear up some of the confusion surrounding the common terms used to refer to spine-related musculoskeletal conditions. For each term we’ll provide a definition, overview, list of common symptoms, causes, methods of diagnosis, and common treatments. In this post, we’re going to briefly look at spondylosis, and then in later posts we will take a more in depth look at some other spine-related conditions.
Spondylosis
Definition: This is an umbrella term used to broadly describe degeneration in the spine. Some doctors may use it interchangeably with spinal osteoarthritis. Spondylosis is a descriptive term rather than a clinical diagnosis – it is used to describe anyone suffering from both pain and spinal degeneration. If your doctor uses this term to describe your condition, you may want to your physician for a more specific diagnosis.
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] Dias, Ana Giselle Aguiar, et. al, Prevalence of repetitive strain injuries/work related musculoskeletal disorders in different specialties of dentists, RGO, Rev. Gauch. Odontol. Vol. 62 no. 2, Campinas Apr./June 2014, http://dx.doi.org/10.1590/1981-8637201400020000042714 (citing Regis Filho GI, Michels G, Sell I. Lesões por esforços repetitivos/distúrbios osteomusculares relacionados ao trabalho em cirurgiões-dentistas. Rev Bras Epidemiol. 2006;9(3):346-59, http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1415-790X2006000300009&lng=en).
[2] Kristina Lynch, My back is hurting my practice, Part I, AGD Impact, Feb. 2006.
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/
Do I Have to Keep Paying Premiums Even Though I’m Disabled?
If you are thinking about filing a disability claim, you are likely wondering whether you will be able to meet your monthly expenses if you’re no longer able to work. You may have made a list of your necessary expenses, and likely included your disability insurance premium payments on that list, as your agent likely told you that your policy would lapse and you would lose your coverage if you missed a premium payment. At this point, you probably started to wonder whether you still have to keep paying the premium after you file the disability claim, and if so, for how long?
The answer depends on the specific terms of your policy. The paragraph that you’ll want to look for when you’re reviewing your policy is typically titled “waiver of premium,” but some policies address waiver of premiums as part of a larger section of the policy that discusses premiums more generally.
How Do Waiver of Premium Provisions Work?
Generally speaking, waiver of premium provisions state that your disability insurance company cannot charge premiums during periods of time when you are disabled. A waiver of premium provision typically will also require your insurance company to reimburse you for premiums you have previously paid during your period of disability (i.e. the premiums that you paid while the insurance company was investigating your claim).
Waiver of premium provisions are included in most disability insurance policies. If you are considering purchasing a policy that does not include a waiver of premium provision, you may have the option to purchase a waiver of premium rider.
Here is an example of a waiver of premium provision from an actual disability insurance policy.
————————————————————————————————————————————
Waiver of Premium Benefit
We will waive Premiums of this Policy from the date of Total Disability after the later of:
- 90 consecutive days of Total Disability, or
- The end of the Elimination Period.
When we approve the Waiver of Premium, We will refund any Premiums paid from the first day of Total Disability. Waiver of Premium will continue while You are receiving a Total or Partial Disability Benefit of this Policy or a Rider. When You are no longer eligible for Waiver of Premiums, You must resume payment of Premiums to keep Your Policy in force.
————————————————————————————————————————————
Under this policy, the waiver of premium provision requires you to pay premiums either for 90 consecutive days after you become disabled, or until the end of the elimination period (the elimination period is the number of days you must be disabled before you are entitled to benefits, and is usually noted on the first few pages of a policy).
So, for example, under this policy, once you have been disabled for 90 consecutive days, you no longer would have to pay premiums (at least until you recover from your disability, or your insurer terminates your benefits). You also would receive a refund of any premiums that you paid for any period prior to your date of disability.
Notably, the waiver of premium provision above also requires you to be receiving benefits for the waiver to apply. This is significant because, depending on the terms of your policy, in some cases you could be disabled but not receiving benefits. For instance, your policy might have a foreign residency limitation that prevents you from receiving benefits if you are living in another country, even if you remain disabled. In such a case, you might have to resume paying premiums until you returned to the United States in order to keep your coverage in force.
The Takeaway
Timely and proper payment of premiums is critical, as a failure to pay premiums can result in you losing your disability coverage completely. It is important to read your disability insurance policy carefully so that you have a clear understanding of when you are required to pay premiums, and when you are entitled to a refund of past premiums.
Most insurance companies will provide you with written confirmation that premiums have been waived, and it is best to keep paying your premiums until you receive this written confirmation, even if you think that you no longer have an obligation to pay premiums under the terms of your policy. If you have questions about whether your insurance company should have waived and/or refunded premiums under the terms of your policy, an experienced disability insurance lawyer can review your policy and explain your rights and obligations under your particular policy.
Don’t Owe Your Insurer Money – Be Aware of Overpayment Provisions
In previous posts, we’ve discussed how insurance companies typically place caps on how much disability coverage a policyholder can receive. For physicians and dentists, this typically results in monthly disability benefit amounts that are lower (and sometimes much lower) than the monthly income you would bring in if you were still able to practice.
In some cases, policyholders are able to supplement their income by working in another field, but this is only possible if your disability insurance policy allows you to work in another occupation. Alternatively, your policy could contain a “no work” provision, which would foreclose this as an option. And some newer policies even require you to be working in order to collect disability benefits, so you don’t have a choice–you must find another job if you want to receive your disability benefits each month.
If you are not able to work in another occupation, due to the nature of your disabling condition and/or the contractual terms of your policy, you may be placed in a position where you must either cut expenses, find another source of income, or both. If you find yourself in this unenviable position, or you are planning ahead and contemplating what you might do in this sort of situation, you will want to keep in mind that some policies–particularly employer-sponsored plans–can contain offset provisions, which allow the insurance company to reduce your monthly disability benefit if you receive additional income from certain enumerated sources.
What Types of “Other Income” Can Be Offset?
There are many types of income that your disability insurer might include in an offset provision. Some examples include:
- Social Security benefits;
- Pension plans;
- Sick leave or a salary continuation plan of an employer;
- Income from other disability insurance policies;
- Retirement benefits funded by an employer;
- Workers’ compensation;
- Partnership or shareholder distributions; or
- Amounts paid because of loss of earning capacity through settlement, judgment, or arbitration.
The list above is by no means exhaustive and, again, you should carefully review your disability insurance policy for its specific list of offsets.
What are Overpayment Provisions?
If your disability insurance policy contains an offset provision, it will also likely contain an overpayment provision. In most instances, if your policy contains an offset provision, your insurer will be able collect information about your income from other sources prior to issuing the disability benefit, and calculate the amount due accordingly. However, in some cases this is not possible.
For example, say you applied for Social Security disability benefits. In some cases, it can take several years before a Social Security determination is made. Then, at that point, if your disability claim was approved, you would receive a lump sum of benefits covering the time period from the date of disability you reported to the date your claim was approved.
This is where the overpayment provision kicks in. If your policy has an overpayment provision, upon learning of the lump sum payment from Social Security, your insurer could potentially require you to pay the entire lump sum of benefits back to your insurance company (depending on the terms of your policy). This is because the lump sum payment represents several monthly payments you would have received over the relevant time frame. If your insurer paid the full monthly disability benefit for those months and your policy has an offset provision, your insurer will likely ask for the Social Security benefits as payment for the amounts that should have been offset each month over that time period.
What Happens if You Cannot Pay Back the Overpayment in a Lump Sum?
If you are not in a position to pay back an overpayment in a lump sum, your disability insurer will seek to collect the overpayment amount in other ways. One way is reducing and/or withholding future disability benefits until the full amount of the overpayment has been recouped by the insurer. Your insurer may also work out a payment plan with you, initiate collection efforts against you and/or file suit to recover the overpayment.
The Takeaway
Offset and overpayment provisions can be particularly devastating if you are caught unaware and find yourself with considerably less income than expected, or an obligation to repay a large sum to your insurer. When selecting a disability insurance policy, you should try and avoid these types of provisions if at all possible. If you already have a policy, you should read it carefully, so that you are fully aware of any offsets that could occur and any overpayments that you could potentially be responsible for under the terms of your disability policy.
Can You Move Out of the Country and Still Receive Disability Benefits?
The answer depends on what your disability policy says. Many people don’t realize that their disability insurance policy may limit their ability to receive disability benefits if they move out of the country. If you’ve ever wondered why claims forms ask for your updated address, one of the reasons might be that your disability policy contains a foreign residency limitation, and your insurance company is trying to figure out if they can suspend your disability benefits.
Foreign residency limitations allow disability insurance companies to stop paying benefits under your policy if you move out of the country. These limitations may be especially relevant if you have dual citizenship, you want to visit family living abroad, or you plan to obtain medical care in another country. A foreign residency limitation may also affect you if your disability insurance policy allows you to work in another occupation and you have a job opportunity in another country that you want to pursue. For instance, if you are a dentist and can receive disability benefits while working in another occupation, your insurance company may suspend your benefits if the opportunity you pursue is in another country.
Foreign residency limitations benefit disability insurance companies in several ways. By requiring you to remain mostly in the country while receiving benefits, these limitations simplify the payment process and reduce the possibility that insurers will need to communicate with doctors in other countries to manage your claim. They also make it easier for insurance companies to schedule field interviews and conduct surveillance of you to find out if you have done something that could be interpreted as inconsistent with your claim.
While these limitations are not included in every disability insurance policy, it is important to check if your policy—or a policy you are considering purchasing—contains a foreign residency limitation, because it could limit your ability to collect benefits later on.
Foreign residency limitations vary by policy. Here is an example of one foreign residency limitation from a Guardian policy:
————————————————————————————————————————————
Limitation While Outside the United States or Canada
You must be living full time in the 50 United States of America, the District of Columbia or Canada in order to receive benefits under the Policy, except for incidental travel or vacation, otherwise benefits will cease. Incidental travel or vacation means being outside of the 50 United States of America, the District of Columbia or Canada for not more than two non-consecutive months in a 12-month period. You may not recover benefits that have ceased pursuant to this limitation.
If benefits under the Policy have ceased pursuant to this limitation and You return to the 50 United States of America, the District of Columbia or Canada, You may become eligible to resume receiving benefits under the Policy. You must satisfy all terms and conditions of the Policy in order to be eligible to resume receiving benefits under the Policy.
If You remain outside of the 50 United States of America, the District of Columbia or Canada, premiums will become due beginning six months after benefits cease.
————————————————————————————————————————————
This limitation highlights several details you should look for if your disability policy contains a foreign residency limitation, including the length of time you can spend in another country before your insurance company will suspend your disability benefits, whether you can resume receiving disability benefits if you return to the country, and when you will have to resume paying premiums if your insurance company suspends your disability benefits. Another important consideration is the effect a foreign residency limitation will have on your policy’s waiver of premium provision. Under the policy above, premiums will continue to be waived for six months after benefits are suspended. However, your disability insurance policy may have a different requirement regarding payment of premiums, so it’s important to read your policy carefully.
Here is an example of another foreign residency limitation from a different Guardian policy:
————————————————————————————————————————————
Foreign Residency Limitation
We will not pay benefits for more than twelve months during the lifetime of this policy when you are not a resident of the United States or Canada.
————————————————————————————————————————————
This limitation contains much less detail than the first limitation. For instance, it does not clarify how suspension of disability benefits will affect waiver of premium. If your disability policy contains a foreign residency limitation that does not discuss waiver of premium, you should look to your policy’s waiver of premium provision to find out when premiums will become due after disability benefits are suspended. The policy above also defines foreign residency differently than the first policy. At first glance, it may seem that you can continue to receive disability benefits any time you leave the country for twelve months or less. What the policy actually says, though, is that the insurance company will only pay benefits for twelve months that you are out of the country at any time you are covered by the policy. So, if you have received disability benefits for twelve months while living in another country—even if those months were spread out over several years—your insurance company will not pay benefits in the future unless you are in the United States or Canada.
As you can see, foreign residency limitations vary among disability policies. If you are thinking about leaving the country, it is important to read your disability insurance policy carefully first so that you understand how leaving the country may affect your ability to recover disability benefits.
Can You Move Out of the Country and Still Receive Disability Benefits?
The answer depends on what your disability policy says. Many people don’t realize that their disability insurance policy may limit their ability to receive disability benefits if they move out of the country. If you’ve ever wondered why claims forms ask for your updated address, one of the reasons might be that your disability policy contains a foreign residency limitation, and your insurance company is trying to figure out if they can suspend your disability benefits.
Foreign residency limitations allow disability insurance companies to stop paying benefits under your policy if you move out of the country. These limitations may be especially relevant if you have dual citizenship, you want to visit family living abroad, or you plan to obtain medical care in another country. A foreign residency limitation may also affect you if your disability insurance policy allows you to work in another occupation and you have a job opportunity in another country that you want to pursue. For instance, if you are a dentist and can receive disability benefits while working in another occupation, your insurance company may suspend your benefits if the opportunity you pursue is in another country.
Foreign residency limitations benefit disability insurance companies in several ways. By requiring you to remain mostly in the country while receiving benefits, these limitations simplify the payment process and reduce the possibility that insurers will need to communicate with doctors in other countries to manage your claim. They also make it easier for insurance companies to schedule field interviews and conduct surveillance of you to find out if you have done something that could be interpreted as inconsistent with your claim.
While these limitations are not included in every disability insurance policy, it is important to check if your policy—or a policy you are considering purchasing—contains a foreign residency limitation, because it could limit your ability to collect benefits later on.
Foreign residency limitations vary by policy. Here is an example of one foreign residency limitation from a Guardian policy:
————————————————————————————————————————————
Limitation While Outside the United States or Canada
You must be living full time in the 50 United States of America, the District of Columbia or Canada in order to receive benefits under the Policy, except for incidental travel or vacation, otherwise benefits will cease. Incidental travel or vacation means being outside of the 50 United States of America, the District of Columbia or Canada for not more than two non-consecutive months in a 12-month period. You may not recover benefits that have ceased pursuant to this limitation.
If benefits under the Policy have ceased pursuant to this limitation and You return to the 50 United States of America, the District of Columbia or Canada, You may become eligible to resume receiving benefits under the Policy. You must satisfy all terms and conditions of the Policy in order to be eligible to resume receiving benefits under the Policy.
If You remain outside of the 50 United States of America, the District of Columbia or Canada, premiums will become due beginning six months after benefits cease.
————————————————————————————————————————————
This limitation highlights several details you should look for if your disability policy contains a foreign residency limitation, including the length of time you can spend in another country before your insurance company will suspend your disability benefits, whether you can resume receiving disability benefits if you return to the country, and when you will have to resume paying premiums if your insurance company suspends your disability benefits. Another important consideration is the effect a foreign residency limitation will have on your policy’s waiver of premium provision. Under the policy above, premiums will continue to be waived for six months after benefits are suspended. However, your disability insurance policy may have a different requirement regarding payment of premiums, so it’s important to read your policy carefully.
Here is an example of another foreign residency limitation from a different Guardian policy:
————————————————————————————————————————————
Foreign Residency Limitation
We will not pay benefits for more than twelve months during the lifetime of this policy when you are not a resident of the United States or Canada.
————————————————————————————————————————————
This limitation contains much less detail than the first limitation. For instance, it does not clarify how suspension of disability benefits will affect waiver of premium. If your disability policy contains a foreign residency limitation that does not discuss waiver of premium, you should look to your policy’s waiver of premium provision to find out when premiums will become due after disability benefits are suspended. The policy above also defines foreign residency differently than the first policy. At first glance, it may seem that you can continue to receive disability benefits any time you leave the country for twelve months or less. What the policy actually says, though, is that the insurance company will only pay benefits for twelve months that you are out of the country at any time you are covered by the policy. So, if you have received disability benefits for twelve months while living in another country—even if those months were spread out over several years—your insurance company will not pay benefits in the future unless you are in the United States or Canada.
As you can see, foreign residency limitations vary among disability policies. If you are thinking about leaving the country, it is important to read your disability insurance policy carefully first so that you understand how leaving the country may affect your ability to recover disability benefits.
Disability Insurance: What Residents Need to Know – Part 4
Previous posts in this series discussed why residents should secure disability coverage sooner rather than later and examined some important terms and provisions to look for in choosing a disability insurance policy. In this final post, we’ll be discussing some provisions that allow you to increase your monthly disability benefits.
As a medical resident, you likely will not be able to obtain a high amount of disability coverage at first, due to your limited income. Consequently, it is important to look for a disability policy that offers a way to increase your benefits in the future, as your earning capacity and expenses increase. You can also, of course, just purchase an additional disability policy if you want to increase your monthly benefit amount, but there can be certain advantages to building benefit increases into your disability insurance policy from the start. For example, if your policy has a future increase option provision, you can typically increase the monthly benefits without undergoing any additional medical underwriting (which could otherwise result in exclusions being added to your policy if you have recently suffered from a new medical condition).
Here are a few of the most common methods of increasing the monthly disability benefit of an existing disability policy:
The automatic benefit increase rider adjusts your monthly disability benefit on an annual basis to account for anticipated increases in income after you purchase your disability insurance policy. The annual increases are typically for a term of five years, after which you will generally be required to provide evidence of your increased income in order to renew the rider.
This policy rider guarantees you the right to purchase additional disability coverage at predetermined dates in the future without going back through the long and tedious process of reapplying for a disability insurance policy. These riders can be attractive because often no additional medical underwriting is required. Most insurers will not allow you to purchase this rider after age 45.
Cost-of-Living Adjustment (COLA)
A COLA rider automatically increases your disability benefit amount by a certain percentage every year to account for increased cost-of-living due to inflation.
Assuming that you will not face a short or long-term disability until you are older is not a risk you want to take. An individual disability insurance plan is a key component in making sure you are financially stable in the event you are no longer able to practice medicine in your chosen field. However, not all plans are created equal. Take the time to evaluate your financial goals and look carefully at the disability benefits provided by the basic terms, provisions, and riders of the disability insurance policy you are considering.
Disability Insurance: What Residents Need to Know – Part 3
In our previous posts in this series, we examined why residents should not wait to acquire disability coverage and discussed some key provisions to look for when selecting an individual disability policy. In this post, we’ll be taking a look at a few more provisions you may want to look for when selecting a disability insurance policy. More specifically, we are going to look at some policy provisions that can help you meet your monthly expenses in the event of disability, along with some policy provisions that can help you plan for your retirement.
Student Loan Coverage Rider
If you are like most residents, you have accrued a significant amount of student loan debt. The time it takes to pay off student loan debt varies widely based on income and other expenses. Many doctors must practice for several years before they are able to pay off all of their student loans, and student loan obligations can be a significant monthly expense to meet if you are disabled and no longer able to practice. Although not as common as other riders, a student loan coverage rider allows policy holders to insure their student loan for an additional amount each month, on top of their disability benefits.
This provision allows you to forego paying your policy premiums while you are receiving disability benefits, freeing up a substantial portion of the monthly income you would otherwise be paying back to the insurance company.
This provision, while not as common, entitles the policy holder to receive a refund of all premiums if he or she does not become disabled before the expiration of the policy term. This can be appealing to residents, whose plans will be in effect for a long time.
This important provision in a policy controls the period of time the insured is eligible to receive disability benefits. Most plans pay benefits until age 65 or 67, some pay lifetime benefits, and others pay for only a limited amount of time, even if a claim is filed decades before the policy terminates.
Retirement Income
The majority of doctors under 40 list preparing for retirement as their top financial goal.[1] There are several different disability policy riders directed towards this goal, including the following.
Graded Lifetime Benefit Rider: This provision, based on its terms, extends some or all of your disability benefits past the normal end date of age 65 or 67.
Lump Sum Rider: This rider provides for a one-time payment once the policy expiration age is reached. Typically, policy holders must have received disability benefits for at least one year and the lump sum payment is typically a percentage of the aggregate sum of disability benefits received during the policy term.
Retirement Protection Insurance: Depending on the insurer, this may be offered as a rider or a stand-alone policy. If you become disabled and your claim is approved, your insurer will establish a trust for your benefit, where disability benefits are deposited and invested (similar to an employer-sponsored 401(k)), with funds likely becoming accessible after the age of 65.
Our next post in this series will discuss the importance of choosing a plan where disability benefits increase over time.
[1] 2015 Report on U.S. Physicians’ Financial Preparedness, Young Physicians Segment, American Medical Association Insurance, https://www.amainsure.com/reports/2015-young-physician-report/index.html?page=5.
Disability Insurance: What Residents Need to Know – Part 2
In our previous post, we looked at how important it is for residents to have a plan to protect themselves financially in the unfortunate event they become disabled. In this post we will address some critical terms to look for when comparing potential disability policies.
Perhaps the most important provision in your disability insurance policy is the definition of “Total Disability.” For physicians, dentists, and other highly specialized professionals who have invested both years and hundreds of thousands of dollars in their careers, a policy that defines “Total Disability” in terms of your inability to perform the specific duties of your “own occupation” (as opposed to “any occupation”) is critical. If your policy defines “Total Disability” as being unable to work in “any occupation,” it will be much more difficult to establish that you are entitled to benefits, in the event you suffer from a disabling condition.
In addition to knowing and understanding your policy’s definition of “total disability,” it is also crucial to know how working in another profession is treated by your disability insurance policy. For instance, if you happened to be an oral surgeon with an essential tremor, you may no longer be able to operate safely on patients, but you may still be able (and want) to teach. Alternatively, if you happened to be a physician who did not take steps to increase your disability coverage to match your increases in earnings, working in another capacity may be the only way to maintain your lifestyle in the event of disability. Consequently, it is also important to know if your policy will allow you to work in another capacity and still collect disability benefits. Along those lines, here are a few other provisions you will want to watch out for:
No Work Provisions
These provisions mandate that you cannot work in another field and still receive disability benefits. This can be problematic if you do not have sufficient disability coverage to meet all of your financial needs.
These types of provisions require you to work in another occupation. This, of course, can make it impossible to collect on your disability benefits if your disability prevents you from working.
In our next post we will look at how you can select a plan that grows with you over time, as both your financial obligations and income change.
Disability Insurance: What Residents Need to Know – Part 1
As a medical resident who is just starting out, you have likely heard about disability insurance, but you may not know a lot about what it is, and why it is important. In this series of posts, we will be discussing a few things that every medical resident should know about disability insurance.
In this post we will look at the likelihood of disability, and discuss how you can begin to protect yourself now and in the future. In subsequent posts we’ll address some of the key provisions to look for in a disability insurance policy, ways to make sure your policy meets current and future expenses, and ways to increase your disability benefits over time, as both your earning potential and financial obligations expand.
Likelihood of Disability
As a resident, you are beginning what will hopefully be a long and successful career as a physician. The possibility of suffering either a short or long-term disability is probably the last thing on your mind, especially if you are still young and healthy. However, the American Medical Association (AMA) reports that 60% of surveyed physicians have a colleague who has sustained a disability accident or injury.[1] A Social Security Administration report shows that it is significantly more likely that a worker born in 1996 will become disabled during his or her career than die,[2] and just over 1 in 4 of today’s twenty-year-olds will become disabled before they retire.[3]
Protection Against Disability
The majority of young doctors under 40 are married, have children, are homeowners, and 75% report that they are their family’s primary breadwinner.[4] Young doctors also face substantial student loan debt, totaling around $166,750, on average. With a resident’s salary averaging just $50,000 a year,[5] it can be tempting to put off adding the additional expense of an insurance premium. However, with most young doctors having less than $50,000 in an emergency fund [6], it’s never too early to start planning to protect your family and provide for care in the unfortunate event you can no longer practice.
While many residents and doctors choose to take part in disability plans offered by their employers, these plans will often not provide adequate coverage, and any disability benefits you do receive will likely be taxable. In contrast, an individual plan provides coverage that is yours as you move from your residency and through (potentially) many different employers. Individual plans also typically allow you to adjust your disability coverage as your income potential grows.[7] However, not all individual policies are created equal and it is important to carefully choose a disability insurance policy.
In our next post, we’ll examine some key provisions to be aware of when shopping for an individual disability insurance policy.
[1] Robert Nagler Miller, Residents: Your disability insurance coverage may fall short, AMA Wire, April 4, 2017, https://wire.ama-assn.org/life-career/residents-your-disability-insurance-coverage-may-fall-short
[2] Johanna Maleh and Tiffany Bosley, Disability and Death Probability Tables for Insured Workers Born in 1996, Social Security Administration, Office of the Chief Actuary, Actuarial Note, No. 2016.6, October 2016.
[3] You, disabled? What are your chances?, The Council for Disability Awareness, 2015, http://www.disabilitycanhappen.org/chances_disability/
[4] 2015 Report on U.S. Physicians’ Financial Preparedness, Young Physicians Segment, American Medical Association Insurance, https://www.amainsure.com/reports/2015-young-physician-report/index.html?page=5
[5] Kathy Kristof, $1 million mistake: Becoming a doctor, CBS Money Watch, Sept. 10, 2013, http://www.cbsnews.com/news/1-million-mistake-becoming-a-doctor/
[6] 2015 Report, Supra.
[7] Miller, Supra.
[8] 2015 Report, Supra
Chronic Pain and Anxiety Disorders
Chronic pain by itself is often debilitating, and the struggle to obtain a correct diagnosis, effective pain management, and ongoing treatment can be stressful and overwhelming. As we discussed in a previous post, depression often co-occurs with chronic pain, and can further complicate treatment. The same is true of anxiety disorders.
Chronic Pain Disorders Associated with the Co-Occurrence of Anxiety
Like depression, anxiety is more likely to co-occur with certain conditions, such as:
- Back Pain
- Neck Pain
- Joint Pain
- Arthritis
- Migraines
- Fibromyalgia
It is no secret that physicians and dentists have stressful and demanding careers. One Cardiff University study showed that of 2,000 British doctors, at various stages of their careers, 60% had experienced mental illness.[1] Often practitioners ignore or fight through both chronic pain and anxiety and show up to work, to the point of endangering themselves or others before acknowledging their disability or seeking adequate treatment.
While anxiety alone can result in an inability to practice, either indefinitely or in the short-term, it is also quite common in those suffering from chronic pain to experience an anxiety disorder. Anxiety disorders are also the most common type of psychiatric disorders in the United States, with 19 million adults affected.[2]
Chronic Pain and Anxiety—Worse Together
Facing a long-term or permanent disability can be anxiety provoking for a physician or dentist, who must (1) face giving up a career he or she invested so much time and financial resources to establish; (2) seek a correct diagnosis, course of treatment, and adequate pain management; and (3) often struggle with adapting to the loss of a previously enjoyed quality of life. Conversely, chronic pain is also common in people with anxiety disorders,[3] with up to 70% of people with certain medical conditions (including hypertension, diabetes, and arthritis) had an anxiety disorder first.[4]
Regardless of whether anxiety or chronic pain came first, individuals suffering from anxiety can experience pain that is particularly intense and hard to treat.[5] In a 2013 study, 45% of 250 patients who had moderate to severe chronic joint or back pain screened positive for at least one of the common anxiety disorders (generalized anxiety, social anxiety, PTSD, OCD). Further, those that had an anxiety disorder reported significantly worse pain and health-related quality of life than their counterparts without anxiety.[6]
Symptoms of Anxiety[7]
There are several anxiety disorders and, while the below list is by no means exhaustive, sufferers of anxiety often exhibit the following symptoms:
Generalized Anxiety Disorder
- Difficulty controlling worry
- Restlessness, feeling wound-up or on edge, irritability, muscle tension
- Being easily fatigued and problems with sleep
- Difficulty concentrating or having their minds go blank
Panic Disorder
- Sudden and repeated attacks of intense fear
- Feelings of being out of control during a panic attack
- Intense worries about when the next attack will happen
- Avoidance of places where panic attacks have occurred in the past
Social Anxiety Disorder
- Feeling highly anxious about being around other people (including having a hard time talking to them, blushing, sweating, trembling, or feeling sick to your stomach)
- Feeling self-conscious in front of others and worried about feeling humiliated, embarrassed or rejected, or fearful of offending others
- Worrying before an event and/or avoiding places where there are other people
- Having a hard time making and keeping friends
Post-Traumatic Stress Disorder
- Flashbacks, bad dreams, difficulty sleeping, frightening thoughts, angry outbursts
- Avoiding places, events, objects, thoughts, or feelings that are reminders of the traumatic experience and trouble remembering key features of the traumatic event
- Being easily startled and feeling tense or “on edge”
- Negative feelings about oneself or the world, and distorted feelings like guilt or blame
- Loss of interest in enjoyable activities
Obsessive Compulsive Disorder
- Fear of germs or contamination
- Unwanted or forbidden thoughts, including aggressive thoughts towards others or self
- Having things symmetrical or in perfect order; excessive clearing and/or hand washing; ordering and arranging things in a precise way; repeatedly checking on things; compulsive counting
Treatments for Anxiety
Some of the treatments that have been successful in addressing anxiety in those with chronic pain include:
- Cognitive-behavioral therapy (CBT)
- Psychodynamic therapy (talk therapy)
- Support groups
- Relaxation or meditation training
- Alternative treatments, such as acupuncture and hypnosis
- Exercise
- Medication
Chronic pain sufferers who recognize any of the above-referenced symptoms in themselves should talk to their doctor to address these serious issues.
[1] Michael Brooks, Why doctors’ mental health should be a concern for us all, NewStatesmen, April 11, 2016, http://www.newstatesman.com/politics/health/2016/04/why-doctors-mental-health-should-be-concern-us-all
[2] What are Anxiety Disorders?, Global Medical Education, https://www.gmeded.com/gme-info-graphics/what-are-anxiety-disorders
[3] Chronic Pain, Anxiety and Depression Association of America, April, 2016, https://www.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/chronic-pain
[4] Global Medical Education, Supra.
[5] Celeste Robb-Nicholson, M.D., The pain-anxiety-depression connection, Harvard Health Publications, http://www.health.harvard.edu/healthbeat/the-pain-anxiety-depression-connection
[6] Health Behavior News Service, part of the Center for Advancing Health, Chronic pain sufferers likely to have anxiety, ScienceDaily, May 8, 2013, https://www.sciencedaily.com/releases/2013/05/130508213112.htm
[7] Definitions according to National Institute of Mental Health: https://www.nimh.nih.gov/index.shtml
I used to practice __________ but now I’m _____________?
As a dentist or physician, you spent years in school and invested countless hours to establish and maintain your practice. You even protected this investment by purchasing a disability policy. Yet, if you do become disabled and make a claim, your insurer might still make the argument that you are only trying to retire and get paid for it. Unfortunately, disability insurance claims by doctors and other healthcare professionals are especially targeted for denial or termination.
When you are disabled and are no longer able to practice in your profession, it may seem logical to simply refer to yourself as “retired,” especially if you are not working in another capacity. While it’s certainly understandable that you may not want to explain to everyone who asks why you’ve hung up your lab coat, you need to keep in mind that innocently referring to yourself as retired will likely prompt your insurer to subject your claim to higher scrutiny. Insurance companies often attempt to take statements out of context in order to deny or terminate disability benefits by alleging that a legitimately disabled claimant is:
- Malingering
- Making a lifestyle choice.
- Unmotivated by or unsatisfied with work.
- Embracing the sick role.
Remember, in the insurance company’s mind, there is a big difference between “disabled” and “retired.” Below are some common situations where you should avoid referring to yourself as retired:
- When asked for your profession on disability claim forms.
- When talking to your doctors or filling out medical paperwork.
- On your taxes, other financial forms, and applications.
- Around the office.
- At social functions or gatherings.
- On social media.
Disability insurers can—and often do—employ private investigators to follow claimants on social media; interview staff, family, or acquaintances; and track down “paper trail” documents (such as professional license renewal forms, loan applications, etc.) to see if you have made any statements that could be construed as inconsistent with your disability claim. Disability insurers also routinely request medical records and may even contact your doctor(s) directly regarding your disability. So, for example, saying something off-hand or even jokingly, such as “I’m retired—I can stay out as late as I want now!” to your doctor, or at a social event like a block party, could lead to your insurer trying to deny your claim if they later spoke to your doctor or your neighbor.
While the focus of your disability claim should be on your condition and how it prevents you from working, insurance companies can latch on to innocent statements like this in an effort to deny legitimate claims. Eschewing the word “retirement” is a good and easy first step to help avoid unwanted and unwarranted scrutiny from disability insurers.
Attorney Ed Comitz Posts CE Course on Dentaltown
Ed Comitz’s Continuing Education course “Disability Insurance Roulette: Why is it So Hard to Collect on My Policy” is now available through Dentaltown. This CE is an electronically delivered, self-instructional program and is designated for 2 hours of CE credit. In this course, Ed discusses why it is so difficult for dentists to collect disability benefits and how to avoid the most common mistakes made by dentists when filing disability claims. Ed also covers the key provisions to look for in disability insurance policies and provides an overview of the disability claims process. Finally, the course discusses how disability insurance claims are investigated and administered, and identifies common strategies used by insurance companies to deny claims.
Information on how to register can be found here.
For more information regarding what to look for in a policy, see this podcast interview where Ed Comitz discusses the importance of disability insurance with Dentaltown’s Howard Farran.
Are Benefits Taxable?
The Answer Is: It Depends
Whether your disability benefit payments are taxable depends on what type of disability insurance policy or plan you have and how your premiums are paid. This post is not intended as tax advice—we’ve outlined some basic information below only. You should always speak with a tax professional regarding your particular situation.
Individual Policies: These are disability insurance policies that you purchase yourself. Generally speaking, if you pay the premiums with after-tax dollars, the disability benefits you receive are tax free. However, if you pay with pre-tax dollars or deduct your premiums as a business expense, then your disability benefits will likely be subject to federal income taxation.
Group Policies: Group policies are those offered through associations such as the ADA or AMA. These types of disability insurance policies offer special terms, conditions, and rates to members and function much like individual policies, with similar tax consequences. Generally speaking, if you pay the premiums (with after-tax dollars) then the disability benefits you receive are tax free.
Employer-Sponsored Policies: These types of disability insurance policies can be less straightforward when it comes to taxes, as the payment of premiums can be structured several ways. According to the IRS website:
- If your employer pays the premium and does not include the cost of the premiums in your gross income, then disability benefits you receive will generally be fully taxable.
- If the employer only offers a policy, but you pay the entire premium without taking a tax deduction, then the disability benefits you receive will generally be tax-free.
- If both your employer and you pay the premiums then the tax liability will generally be split.
If you are unsure what type of disability insurance policy or plan you have, and you think your employer might be paying the premiums, you can look at your application (there is typically a portion that states who is responsible for the premiums) or talk to your HR department. For more information, talk to your accountant. You can also go to to the IRS website on disability insurance proceeds to find additional information.
It may be tempting to save money by enrolling only in a plan solely paid for by your employer, paying premiums with pre-tax dollars, or deducting premiums as business expenses. But keep in mind that, if you do become disabled, the amount of your disability benefits actually available to you will substantially decrease if you are required to pay income tax on them.
Selecting a disability insurance policy is an important decision, and how disability benefits will be taxed is a significant factor to consider. With statistics showing that one in four dentists will be disabled long enough to collect disability benefits at some point in their careers, choosing to save now could hurt you financially down the road.
Chronic Pain and Depression
Chronic pain is often difficult to diagnose and treat. Consequently, those who suffer from chronic pain typically must also deal with a significant amount of stress, due to repeated failed treatments, numerous medical appointments, interruption of work and enjoyable activities, and the inability of their friends or family to understand their physical limitations. This can, in turn, cause or worsen depression. When depression occurs alongside chronic pain, it can make dealing with and treating the pain even harder.
Chronic Pain Disorders Associated with the Co-Occurrence of Depression
While mental health conditions, including depression, can often be disabling in and of themselves, they are unfortunately also quite common in those suffering from chronic pain. Depression is more likely to co-occur with certain conditions, such as:
- Back Pain
- Neck Pain
- Joint Pain
- Arthritis
- Migraines
- Fibromyalgia
Studies show that rates of depression are high in residents and medical students (15%-30%) than rates in the general population, and the risk of depression continues throughout a physician’s career.[1] According to a British study, 60% of dentists reported being anxious, tense, or depressed.
Dentists, doctors, and other medical professionals place extreme amounts of pressure on themselves because the stakes of their professions are so high. In addition to perfectionism and self-criticism, other predictors of depression in doctors include: lack of sleep, stressful interactions with patients and staff, dealing with death, constant responsibility, loneliness, and making mistakes.[2]
Often practitioners work through both chronic pain and psychiatric disorders for some time before acknowledging their disability or seeking adequate treatment. In the case of depression, this can be due in part to the social stigma that surrounds it. For all of these reasons, depression may go undiagnosed or seem less of an immediate concern to those suffering from chronic pain. However, if you are experiencing symptoms of depression and chronic pain, studies show that it is important to treat both, because chronic pain can become much more difficulty to treat if the depression is allowed to progress unchecked.
Chronic Pain and Depression—Worse Together
Facing a long-term or permanent disability can trigger depression—this is especially understandable for doctors or dentists who have put years into medical school and establishing their careers, only to become disabled and have to step away from a profession that has become a significant part of their identity. Depression can also precede chronic pain. For example, several studies have examined the link between depression before the onset of back-pain.[3]
Regardless of which came first, together they are formidable to treat. Major depression is thought to be four times greater in people with chronic back pain than those in the general population, and studies show that individuals suffering from both chronic back pain and depression experienced a greater degree of impairment than those with either depression or back pain alone.[4]
Treatments for Depression
Focusing solely on pain management can prevent both the patient’s and treating physician’s ability to recognize that a psychiatric disorder is also present. Yet, even with correct diagnoses, both issues can be difficult to treat together.[5] For instance, those who suffer from both chronic pain and mental illnesses can have a lower pain threshold as well as increased sensitivity to medication side-effects.[6] Some treatments that have proved successful in addressing depression in those with chronic pain include:
- Cognitive-behavioral therapy (CBT)
- Psychodynamic therapy (talk therapy)
- Relaxation or meditation training
- Acupuncture
- Hypnosis
- Exercise
- Medication
Symptoms of Depression
- Little interest or pleasure in doing things
- Feeling down, depressed, or hopeless
- Trouble falling asleep or sleeping too much
- Feeling tired or having little energy
- Poor appetite or overeating
- Trouble concentrating
- Feeling bad about yourself, or that you are a failure or have let yourself or others down
- Thoughts that you would be better off dead, or hurting yourself in some way
Chronic pain sufferers who recognize any of the above-referenced symptoms in themselves should talk to their doctor to address these serious issues.
_________________________________________________________________________
[1] Robert P. Bright, MD, Depression and suicide among physicians, Current Psychiatry, April 10, 2011.
[2] Id.
[3] William W. Deardorff, PHD, ABPP, Depression Can Lead to Chronic Back Pain, Spine-health.com, Oct. 15, 2004, http://www.spine-health.com/conditions/depression/depression-can-lead-chronic-back-pain.
[4] William W. Deardorff, PhD, ABPP, Depression and Chronic Back Pain, Spine-health.com, Oct. 15, 2004, http://www.spine-health.com/conditions/depression/depression-and-chronic-back-pain.
[5] Celeste Robb-Nicholson, M.D., The pain-anxiety-depression connection, Harvard Health Publications, http://www.health.harvard.edu/healthbeat/the-pain-anxiety-depression-connection.
[6] Anxiety and Depression Association of America, Chronic Pain, https://www.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/chronic-pain.
