Disability Insurer Profiles: Standard
Standard is another disability insurer we will look at that specifically markets its policies to physicians and dentists.
See our profiles of MassMutual, MetLife, Northwestern Mutual, Guardian, and Hartford.
StanCorp Financial Group (“StanCorp”) was founded in 1906 and uses the marketing name “The Standard” to refer to its primary subsidiaries, which include the Standard Insurance Company and the Standard Life Insurance Company of New York. In 2013, StanCorp received $351.7 million in pre-tax income, and $272.4 million (approximately 77%) of that income was attributable to profits from StanCorp’s insurance services. StanCorp is particularly proud of its consistent long term growth and—given the fact that 77% of StanCorp’s profits come from its insurance services—StanCorp has an obvious incentive to deny high paying disability claims submitted by physicians and dentists.
Company: StanCorp Financial Group, Inc.
Location: Portland, Oregon.
Associated Entities: Standard Insurance Company; The Standard Life Insurance Company of New York; StanCorp Investment Advisers, Inc.; Standard Retirement Services, Inc.; StanCorp Mortgage Investors, LLC.
Assets: $22.73 billion in 2014.
Notable Policy Features: If you are considering a Standard disability insurance policy, you should pay particular attention to whether the policy allows for total disability benefits if you are working in another occupation. Oftentimes, Standard policies will pay nothing more than residual disability benefits if you are able to secure other part-time employment. For example, if you can no longer practice dentistry, but you are able to teach classes at a dental college, Standard may refuse to pay you total disability benefits. If you are eligible for residual benefits, Standard will require you to submit proof of your income every single month.
Read more about the difference between total disability benefits and residual disability benefits.
Claims Management Approach: Standard tends to demand strict compliance with its claims procedures, and Standard will generally not be very accommodating if you make a mistake. This can be problematic, because, for many policyholders, the disability claims process is unfamiliar and daunting. If you are dealing with Standard, be sure to ask for a detailed explanation of what is required of you. You should pay close attention to deadlines, as they will likely not be flexible. You should also make sure that you use Standard’s forms when providing attending physician statements or other documentation of your disability, because Standard will not accept other insurers’ forms.
These profiles are based on our opinions and experience. Additional source(s): “Quick Facts About the Standard” and “About the Standard,” available at www.standard.com; StanCorp 2014 KBW Conference Presentation, available at investor.stancorpfinancial.com.
Disability Insurer Profiles: Hartford
Hartford is the next disability insurer we will look at that specifically markets its disability policies to physicians and dentists.
See our profiles of MassMutual, MetLife, Northwestern Mutual, and Guardian.
The Hartford Financial Services Group, Inc. (“Hartford”) was founded over 200 years ago and now has more than 100 offices located throughout the U.S. In 2013, Hartford’s revenues were approximately $26.2 billion. However, in 2014, Hartford’s revenues dropped to $18.6 billion. Given this significant decrease in revenue, Hartford will likely go to great lengths to avoid paying high paying claims submitted by physicians and dentists, and may even attempt to revoke disability benefits that it approved before the company experienced this dramatic drop in profits.
Company: The Hartford Financial Services Group, Inc.
Location: Hartford, Connecticut.
Associated Entities: Hartford Fire Insurance Company; Hartford Life, Inc.; Hartford Accident and Indemnity Company; Hartford Casualty Insurance Company; Hartford Life and Accident Insurance Company; Hartford Life and Annuity Insurance Company; Hartford Life Insurance Company; Property and Casualty Insurance Company of Hartford.
Assets: $245 billion in 2014.
Notable Policy Features: Hartford offers disability insurance policies that define total disability as being unable to perform one of your prior substantial and material duties. If your disability policy contains such a definition, it will be much easier for you to demonstrate that you are totally disabled. In contrast, if your disability policy does not define total disability in this manner, you may have to prove that you cannot perform any of your prior substantial and material duties in order to receive total disability benefits.
Claims Management Approach: Hartford only offers group disability policies (as opposed to individual disability policies). This means that if you have a Hartford policy, it will probably be governed by ERISA. For many reasons, it will likely be harder for you to obtain your disability benefits if your policy is governed by ERISA.
For example, normally, if you become disabled and you have an individual disability policy, you can collect your disability benefits without filing for Social Security. However, if you have a Hartford group policy, your policy may require you to apply for Social Security benefits before you can receive your disability benefits. Hartford requires its policyholders to apply for Social Security because, under ERISA, any Social Security benefits the policyholder receives automatically offset the amount of disability benefits Hartford must pay the policyholder.
Read more about how ERISA claims are treated differently than non-ERISA claims.
These profiles are based on our opinions and experience. Additional source(s): Hartford’s 2014 Annual Report; “The Hartford Fact Sheet (2013),” and “The Hartford Fact Sheet (2014),” available at www.thehartford.com.
Disability Insurer Profiles: Guardian
In the last few posts, we’ve looked at a few of the most common disability insurance companies for doctors. See our profiles of MassMutual, MetLife, and Northwestern Mutual. Guardian is another disability insurer that specifically markets its disability policies to physicians and dentists.
Guardian has been around for over 150 years and is one of the largest individual disability income insurance providers in the United States. Guardian’s business model emphasizes the need for continuous growth, and Guardian reports that it has paid out dividends to its owners every year since 1868. To reach its goal of uninterrupted growth and live up to its owners’ expectations that it will pay out dividends each year, Guardian must not only maintain its past levels of profitability, but also come up with new ways to be more profitable. Obviously, from Guardians’ perspective, denying high paying disability claims submitted by physicians and dentists is an attractive method of increasing its profits.
Company: The Guardian Life Insurance Company of America.
Location: New York, New York.
Associated Entities: The Guardian Insurance & Annuity Company, Inc.; Berkshire Life Insurance Company of America; Guardian Investor Services, LLC; Park Avenue Securities LLC; RS Investment Management Co. LLC; Reed Group, Ltd.
Assets: $84.1 billion in 2013.
Notable Policy Features: Guardian policies oftentimes attach a “Residual Disability Rider” to their disability policies. This rider could impact you in significant ways if you are partially disabled and considering part-time work. For instance, the residual disability rider to your policy might contain the following provisions:
“Income. Income means your gross earned income, less business expenses, but before any other deductions. It includes salaries, wages, fees, commissions, bonuses, business profits or other payments for your personal services.”
“Prior Income. Prior income means your average monthly income for the tax year with the highest earning in the three years just prior to the date on which you became disabled.”
“Current Income. Current income means all income which you receive on a cash basis in each month while you are residually disabled.”
“Loss of Income. Loss of income means the difference between your prior income and your current income.”
“Residual Indemnity. Residual indemnity = (loss of income/prior income) x monthly indemnity.”
“Termination of Residual Indemnity. Residual indemnity will stop when the first of the following events occurs:
- you become totally disabled; or
- the benefit period ends; or
- your loss of income is less than 20% of prior income . . . .”
When read together, these provisions essentially mean that if you are partially disabled and working in another occupation, Guardian includes the additional income earned in that occupation when determining your current monthly income. This is important because you could lose your residual disability benefits if, after adding in your additional income, your loss of income amounts to less than 20% of your prior income. If you have this residual rider in your disability insurance policy, you should be aware that accepting part time work could jeopardize your ability to collect residual disability benefits.
Read more about residual disability benefits.
Claims Management Approach: Like many of the other insurance companies we have profiled, Guardian frequently conducts in-home field interviews, in an effort to catch you off guard and observe you in a state of activity that may not accurately reflect the severity of your condition. In-home field interviews also allow Guardian to collect personal information, such as your daily routine, hobbies and interests, names of friends and family, and work hours, so that its private investigators can more easily conduct surveillance of you.
If your disability claim involves a psychological disability, Guardian will likely require you to submit proof that you are being treated by a PhD level therapist, even if you have been working with a non-PhD level therapist for a significant period of time. Consequently, if you have a Guardian disability insurance policy and are in need of therapy, you might want to consider consulting with a PhD level therapist from the start.
A final tactic frequently used by Guardian is the peer-to-peer call, which consists of Guardian directly contacting your treatment providers over the phone without your consent. This tactic is similar to the in-home field interview in the sense that it is an attempt to catch your treating physicians off-guard by ambushing them with detailed questions about your disability. Since these discussions take place over the phone, your treating physicians will likely not have an opportunity to provide well thought out, thorough answers, and there will likely be little, if any, documentation of the call. Although this tactic is alarming, it is easily countered. As we explained in a previous post, peer-to-peer calls can be preempted in most cases if you have your disability insurance attorney notify the insurance company that all communications with your treatment providers must be coordinated through your attorney’s office.
These profiles are based on our opinions and experience. Additional source(s): Guardian’s 2013 Annual Report; Guardian Fact Sheet 2013; guardianlife.com.
Disability Buyout Policies
Have you ever wondered about disability buyout insurance for doctors and dentists?
Attorney Patrick T. Stanley gives a comprehensive overview of these policies on Comitz Stanley’s healthcare transactions and litigation blog.
Check it out and contact Mr. Stanley with your questions: Disability Buyout Insurance–Protecting Yourself and Your Partners.
Disability Insurer Profiles: Northwestern Mutual
In this series, we’re taking a look at some of the most popular disability insurance companies for doctors. See our profiles of MassMutual and MetLife. Northwestern Mutual is another disability insurer that specifically markets its disability policies to physicians and dentists.
In 2014, the company insured 476,000 people through 727,000 individual disability policies. Northwestern Mutual prides itself on paying more dividends that its competitors. In order to do that, of course, it must maintain consistently high profit levels.
Company: Northwestern Mutual Life Insurance Company.
Location: Milwaukee, Wisconsin.
Associated Entities: Northwestern Long Term Care Insurance Co., Northwestern Mutual Investment Services, LLC, Northwestern Mutual Wealth Management Co., The Frank Russell Co.
Assets: $217.1 billion in 2014.
Notable Policy Features: Northwestern Mutual sells policies with an “own occupation” definition of total disability. However, these disability insurance policies are often only truly “own occupation” for a limited amount of time, after which they become any occupation policies (only providing benefits if you are unable to work in any job) or “no work” own occupation policies (only providing benefits if you are unable to perform your job duties and are not working in another job).
For instance, a Northwestern Mutual policy might include the following definition:
Total Disability. Until the end of the Initial Period [defined elsewhere as 60 months of benefits], the Insured is totally disabled when is unable to perform the principal duties of his occupation. After the Initial Period [i.e., 60 months], the Insured is totally disabled when he is unable to perform the principal duties of his occupation and is not gainfully employed in any occupation.
In order to make sure a Northwestern Mutual disability insurance policy keeps the own occupation definition for as long as you hold the policy, you may need to purchase an additional benefit rider.
Read more about Northwestern Mutual’s interpretation of its own occupation policies.
Claims Management Approach: Some of the claims strategies that Northwestern Mutual is known to use include conducting in-home field interviews on top of third-party surveillance, hiring its own medical consultants to review claimants’ records and opine on whether or not they are disabled, and demanding that claimants (especially those with mental conditions) undergo “independent” medical examinations (IMEs) with providers of Northwestern Mutual’s choosing.
These profiles are based on our opinions and experience. Additional source(s): Northwestern Mutual’s 2013 Annual Report; Northwestern Mutual Fact Sheet 2014; Forbes.com.
Disability Insurer Profiles: MetLife
Today we’re profiling another popular insurer that issues private disability policies to dentists and physicians: MetLife.
Company: Metropolitan Life Insurance Company, a.k.a. MetLife.
Location: New York, NY.
Associated Entities: MetLife, Inc. (parent company), General American Life Insurance Company, New England Life Insurance Company.
Assets: MetLife, Inc. held over $885 billion in assets as of May 2014, according to Forbes.
Notable Policy Features: One thing to watch out for in MetLife disability insurance policies is a limitation on benefits for mental disorders and/or substance use disorder. Under the Limited Monthly Disorders and/or Substance Use Disorders provision of some MetLife policies, policyholders are only entitled to a total of 24 months of benefits for any mental or substance abuse disorder, such as depression, panic disorder, post-traumatic stress disorder (PTSD), bipolar disorder, and alcohol abuse or dependency. The 24 month limitation is cumulative. So, for example, if you have depression that disables you for 23 months, then start suffering from disabling alcohol dependency later in your life, you would only have one month of benefits still available to you.
Claims Management Approach: In its 2013 Annual Report, MetLife, Inc. reported that “unfavorable morbidity experience in our individual income disability business resulted in a $6 million decrease in operating earnings.” In other words, in 2013, more private disability insurance policyholders experienced disabling illnesses or injuries than in years before, and that hurt MetLife’s profits. In these situations, where an insurer is facing increased liability for disability benefit payments, we often see that insurer put additional resources towards managing disability claims. In this way, the insurer can spend extra time and effort looking for ways to deny or terminate disability claims, with the goal of limiting its liability.
In our experience, one way that MetLife attempts to dispose of claims as quickly as possible is by ordering surveillance early on in the claim. While some companies will wait until they have received more information before starting surveillance, MetLife has started following and videotaping claimants within weeks of the claim being filed.
With respect to its medical investigation, we have found that MetLife often follows a similar strategy to MassMutual’s. The insurer will often attempt to have its own medical personnel schedule “peer-to-peer” telephone consultations with claimants’ treating physicians, with the aim of catching the treating physician off guard and persuading them into saying their patient isn’t disabled. However, we have found that, in certain circumstances, MetLife can be amenable to submitting medical questions to the treating doctor in writing instead. That way, the treating doctor can more carefully consider the issues, without feeling pressured or put on the spot.
These profiles are based on our opinions and experience. Additional source(s): MetLife’s 2013 Annual Report; Forbes.com
Disability Insurer Profiles: MassMutual
We have written about Unum, arguably the most notorious disability insurance company, in great detail. However, we realize that many physicians and dentists may not know very much about other disability insurance companies, including those whose policies they own. In the next few posts, we’ll profile some of the most common doctors’ disability insurers.
Company: Massachusetts Mutual Life Insurance Company, a.k.a. MassMutual.
Location: Springfield, Massachusetts.
Associated Entities: Mass Mutual Financial Group (parent company), C.M. Life Insurance Company, MML Bay State Life Insurance Company.
Assets: Over $195 billion in 2013.
Notable Policy Features: As part of its product offerings, MassMutual sells own-occupation disability insurance policies to physicians and dentists. One notable aspect of some MassMutual policies we’ve seen recently is an especially restrictive definition of “Total Disability,” which we sometimes refer to as a “no work” own-occupation definition. Under the “no work” own-occupation definition, an insured is Totally Disabled if he or she is unable to perform the material and substantial duties of his or her own occupation and not working in any occupation. Unlike traditional own-occupation policies that allow a physician or dentist to collect total disability benefits and return to work in a different occupation, this one will not pay total disability benefits if the policyholder is doing any type of gainful work.
Claims Management Approach: MassMutual is a highly successful insurer. In June 2014, it was ranked number 96 in the Fortune 500. However, Fortune reports that MassMutual is currently experiencing a dramatic reduction in profits. If MassMutual follows the current trends in the disability insurance industry, we believe it will increase scrutiny on disability insurance claims in order to try to regain its former profit levels.
In our experience, one of the ways MassMutual aggressively approaches disability claims is to hire a medical consultant to evaluate claimants’ medical records. The consultant then tries to insert himself or herself between the claimant and the treating physician, writing or calling the treating physician and suggesting treatment methods that, in the consultant’s opinion, will get the claimant back to work as soon as possible.
These profiles are based on our opinions and experience. Additional source(s): MassMutual’s 2013 Annual Report; Fortune 500 2014; Bloomberg.com
What to Do When Your
Disability Insurance Claim Is Denied
A large part of our practice consists of helping physicians and dentists whose disability insurance claims have been denied or terminated. When our clients come to us, we carefully analyze their medical records, the claim file, and the law to craft a specific strategy for getting the disability insurer to reverse its adverse determination. Unfortunately, we sometimes find that in between receiving notice that their claim has been denied or terminated and getting in touch with our firm, doctors will inadvertently take actions that prejudice their disability claims. With that in mind, it’s important to review what to do and what not to do in the first few days after your claim is denied or terminated.
- In all likelihood, you will first find out that your insurer is denying or ending your disability benefits via a telephone call from the claims consultant who analyzed your claim. As we’ve explained before, the consultant will be taking detailed notes about anything you say during that call. Therefore, even if you are justifiably upset or angry, be very mindful of what you say. Anything you tell the consultant will certainly be written down and saved in your file.
- During the call with your consultant, make your own notes. You don’t have to ask a lot of questions at this stage, but you do want to make sure to record whatever information the consultant gives you.
- Following the phone call, you should receive a letter from the insurance company stating that it has denied your disability claim or discontinued your disability benefit payments. According to most state and federal law, the letter should have a detailed explanation of the evidence the company reviewed and why the insurer thinks that evidence shows you aren’t entitled to disability benefits. When you receive the letter, read through it carefully. Make notes on a separate document about any inaccuracies you identify.
- Make sure you keep a copy of the denial or termination letter as well as the envelope it came in. You should also make a note of the date on which you received the letter. The date the letter was actually mailed and received could be important to your legal rights in the future. Then, the best thing to do is to scan the documents electronically or make a photocopy for your file, just in case the original denial letter gets lost or damaged.
- Once you find out that your disability claim has been denied or terminated, you should contact a disability insurance attorney. Some doctors and dentists attempt to handle an appeal of their claim on their own, but we strongly suggest at least consulting with a law firm. Every insurance company has its own team of highly-trained claims analysts, in-house doctors, and specialized insurance lawyers to help it support the denial of your claim. Having your own counsel can level the playing field by making sure you know your rights under your policy and what leverage the applicable law provides you, and help you avoid the common traps that insurance companies lay for claimants on appeal.
- The lawyer you consult can be in your area, or it can be a firm with a national practice that’s physically located in another state. You may want to review these questions to ask potential attorneys before you decide who you would like to represent you.
- Whatever attorney you choose to contact, make sure you do so as soon as possible. In many circumstances, you will only have a limited amount of time to appeal the insurance company’s decision. Particularly in claims governed by the federal law ERISA, the clock starts ticking as soon as you find out your disability claim has been denied or terminated.
- It’s usually best to contact a disability insurance attorney before you respond to the denial letter, to avoid saying anything that could prejudice your appeal. For instance, if you have a disability insurance policy that is governed by ERISA, and you submit some additional information, the insurance company may not allow you to submit any additional information after your initial response.
- Before you meet with potential disability insurance lawyers, gather whatever documents you can to help them evaluate what’s going on with your claim. Our firm will always want to review the insurance policy or policies. (Here’s information on how to get a copy of your policy). We typically also like to see your relevant medical records and any correspondence between you and your insurance company. If you aren’t able to locate this information, it could cause delays in starting the appeal process.
- If you are a physician or dentist that is totally disabled, you should not try to go back to work just because your insurance company thinks you don’t qualify for disability benefits. Trying to practice when you aren’t in a physical or mental condition to do so could cause you to re-injure yourself or accidentally harm your patients. Of course, trying to work on patients after you’ve claimed that you are totally disabled can expose you to professional liability as well. Further, trying to return to work could impair your ability to collect your disability benefits upon appeal.
Field Interviews: What to Expect After the Interview Ends
We’ve discussed why a disability insurer might want to schedule a field interview and what to expect before and during the interview itself. Now we review what claimants can expect can expect after the interview ends. Again, the process is usually different depending on whether not a disability insurance attorney is involved.
After the Field Interview
After your interview ends, the field representative will leave to do some additional reconnaissance. Without telling you, the representative may drive to your office to talk to people on your staff. He or she will see what the office looks like, if it’s busy, and whether your name is still listed on the door. If you have a disability insurance attorney, the attorney will have discussed this with you ahead of time, and together you will have taken steps to make sure the representative doesn’t bother your staff or catch them off guard.
Some days after the field interview, the representative will send you a copy of his or her report, which purports to summarize your conversation. The report will ordinarily be 8 to 10 pages or more. He or she will ask you to review the report, make any changes you see fit, and return it. The representative will advise that if you don’t make any changes by a certain date, he or she will assume that everything in the report is accurate.
For claimants with legal representation, the report will be sent to your attorney’s office. Your attorney will review the report to make sure that it accurately reflects the facts of your disability claim. He or she should be able to correct any seemingly harmless statements that a claims adjuster may take out of context to support denying or terminating your disability claim. If any important information is missing, your attorney will make sure to include it along with the report.
Meanwhile, the field representative will usually send a separate report to the insurance company. This second report will have the representative’s personal observations about you, their conversations with your staff, and any other information he or she was able to gather about your outside of the interview. You will not be provided with a copy of this report unless you’re able to obtain the claim file after your disability claim has been terminated or denied. If you have an attorney, this second report will be much more limited, as the representative will not have had the opportunity to visit your home or to pry into irrelevant or confidential information. If your disability claim is denied or terminated, your attorney will obtain and review this report for any inaccuracies or misstatements.
A field interview can be intimidating, but knowing why the interview is being conducted and what to expect during the process can make you better prepared to handle it in a way that doesn’t prejudice your claim. If you have questions or concerns about a field visit, contact a disability insurance lawyer right away.
Field Interviews:
What to Expect Before and During the Interview
Our last post discussed why an insurance company might want to conduct a field visit or field interview. Now that you know what the insurer is trying to accomplish, we’ll discuss what exactly to expect before the interview, during the interview, and afterwards. As with many aspects of the disability claims process, the field interview will be different depending on whether or not you have a disability insurance attorney involved. First, what to expect before and during the interview:
Setting Up the Field Interview
Initially, the field representative will call or e-mail you personally to set up a time to meet. He or she will ask to come to your home, or sometimes your office (particularly if you have been practicing as a dentist or physician), and talk one-on-one. If you’re being represented by a disability insurance lawyer, the field representative will call or write a letter to the lawyer’s office to request a field interview. Your attorney will evaluate whether the in-person interview is necessary and appropriate under the terms of your policy and your particular claim situation. If so, your attorney will likely ask the field interviewer to meet at the attorney’s office, rather than in your home or office. Your attorney, and sometimes an assistant as well, will attend the interview. The attorney and/or his or her assistant will take careful notes of the entire conversation.
During the Field Interview
When the representative arrives, he or she may ask to take your photograph. The representative may also ask to audio-record your conversation. If an attorney is present, the representative will usually refrain from asking to take a photograph or audio-record the conversation, knowing that your legal counsel will likely determine it unnecessary and/or inappropriate.
The field representative will sit down and talk with you for an hour or more. He or she will have an extensive list of questions to ask you, most of which your claims analyst will have specifically requested the representative address. For those with legal representation, your attorney will have prepared you for each of the questions the representative will ask, so you’ll be ready to give accurate and well-considered answers.
During your conversation, the representative will be very warm and friendly. The representative will normally try to establish a rapport so that you’ll relax and talk openly. He or she will try to get you to talk without thinking, encourage you to go into unnecessary detail, and may ask personal questions that a claims adjuster would normally avoid.
The representative often acts somewhat more reserved when a disability insurance attorney is present. Field representatives know that if they ask any questions that are irrelevant, seek confidential information, or are otherwise inappropriate, your attorney will intervene and let you and the representative know that you don’t need to answer the question.
While you’re talking, the field interviewer will take copious notes. These notes will include the interviewer’s own observations about your appearance, how well you move, how long you were able to sit or stand, what your house looks like (if in your home), and whether you seem nervous or not. If your attorney attends, the representative will know that his or her notes will be compared against the attorney’s, so he or she will be especially careful to document the circumstances accurately.
In our next post, we’ll talk about what happens after the field interview ends.
Why Does My Insurer Want to
Conduct a Field Interview?
At some point after you’ve filed a disability insurance claim, your carrier may contact you to arrange a field interview. Also called a “field visit,” a field interview is when a disability insurer hires a representative to come meet with you face-to-face to talk about your benefit claim. Most times, the company will ask that you meet the field representative at your own home or office.
Your claims analyst will probably tell you that the field interview is just a way to get to know you better, or to help the company gain a better understanding of your disability claim. What the claims analyst won’t tell you are the real reasons why insurance companies put so much time and effort into planning in-person field interviews, such as:
- To take your picture so that a private investigator will recognize you during surveillance.
- To find out what your house and/or office looks like to further aid in surveillance.
- To look inside your house and see if you’ve been doing a lot of housework, paperwork, cooking for yourself, etc., all of which (according to the insurance company) can mean you’re able to work in your own occupation.
- To see if you look like you’re in pain, if you can sit down for a long period of time, or if you can walk without any gait abnormalities.
- To see if you look like you might have current monthly income from sources other than your occupation (i.e., if you have a nice car, a big house, a boat, etc.).
- To drop in and try to interview your spouse, former business partners, office manager, or neighbors.
- To try and get you to relax and open up, or to catch you off guard so that you give information the company can use against you.
In our next post, we’ll discuss what you can expect during the field interview itself.
Why Won’t My Doctor Help
With My Disability Insurance Claim?
We frequently discuss how important it is for your treating doctor to support your disability insurance claim. Oftentimes, though, doctors are reluctant to help with the process. Understanding why your provider is hesitant to get involved can better equip you to enlist his or her support.
In our experience, these are the most common reasons why treatment providers decline to assist with disability insurance claims:
They don’t have time. Doctors have extremely busy schedules. Often, they’re concerned that they simply don’t have enough time to properly complete all of the insurance company’s required forms or to answer questions from your claims adjuster.
They are worried about the insurance company harassing them. Many healthcare providers know how complex and combative disability insurance claims can be. Sometimes, providers don’t want to get involved with a claim at all, because they’ve heard of (or experienced) claims personnel harassing treating doctors. This can be a legitimate concern, as left unchecked, insurance companies will often bother treating doctors with repetitive requests for information, pushy phone calls, or by second-guessing the doctors’ treatment plan.
They are worried about doing something to hurt your claim. On the other hand, many providers aren’t familiar with the private disability insurance claims process at all. This sometimes makes providers hesitant to complete Attending Physician’s Statements or to discuss your claim with an adjuster for fear that they will inadvertently say something that prejudices you.
They don’t know the definition of disability in your policy. Not every treatment provider is familiar with the type of own-occupation policy that many physicians, dentists, and other professionals purchase. When some providers hear the word “disability,” they think of a state of total helplessness, or of the much more stringent Social Security definition of “disability.” If a provider doesn’t know that your policy deems you “disabled” if your condition prevents you from performing the duties of your own job, he or she might think you don’t qualify for disability benefits.
Continue reading “Why Won’t My Doctor Help
With My Disability Insurance Claim?”
Understanding Residual Disability Benefits: Are They Worth The Cost?
Part 3 – Current Monthly Income
In our previous posts, we identified the basic formula disability insurers use to calculate residual (partial) disability benefits and discussed variations in how disability insurers calculate Prior Monthly Income. Now, we will examine the other principal component in calculating a residual disability benefit: Current Monthly Income.
Current Monthly Income is the calculation of how much a doctor is earning now, versus how much he was earning prior to his disability. Although this sounds like a simple concept, calculating Current Monthly Income can be challenging in the healthcare industry. Many physicians and dentists own their own practices or are a partner in a practice group. Their income is not only based on their productivity, but also includes a passive component from the other business activities of the practice. For example, a dentist may employ one or more hygienists or associate dentists who generate additional revenue. When a doctor becomes disabled, the practice revenue may remain relatively constant as associates increase their production to account for the doctor’s reduced schedule.
Some insurers take advantage of this by calculating Current Monthly Income not on the doctor’s production, but rather on the practice’s revenue. This fails to take into account the true financial impact of a disability because, while revenue may remain high, expenses increase as associate doctors and hygienists work more (and earn more) to fill in for the disabled doctor.
Additionally, many doctors pay themselves based on a percentage of their own production, in addition to the income they earn as practice owners. When a doctor becomes partially disabled, his income from working in the practice will drop, even if the practice’s overall profitability does not. Depending on the language in a particular disability insurance policy, the policy may not take into account the drop in production, and the doctor may not be able to recover the full loss caused by his disability.
Electronic Medical Records: What You Don’t Tell Your Doctor Might Hurt Your Disability Claim
Over the last ten years, there has been an increasing movement away from paper records and toward Electronic Medical Records (EMR). This move has been accelerated by the federal government’s mandate that doctors who treat Medicare and Medicaid patients must have adopted and implemented EMR systems as of January 1, 2014.
There are many benefits to using EMR. They can facilitate patient care between referring doctors, improve data tracking over time, increase efficiency and reduce errors. However, EMR systems have drawbacks when they are used for purposes never intended, such as to document a disability claim.
Many EMR systems allow the doctor to input his findings for every major system in the human body, such as the cardiovascular, musculoskeletal, gastrointestinal, neurological and psychiatric systems. However, if the doctor does not put in something regarding one of the symptoms, the default setting on the EMR will report the system as being “within normal limits” or that the patient has “no complaints.” The concern with this from a disability perspective occurs when a patient sees his doctor for a condition unrelated to his disability.
For example, a patient with a history of degenerative disc disease could visit his doctor for an unrelated infection or illness. Since the doctor is conducting only a limited examination for purposes of treating the presenting illness, he may not input any information related to the patient’s disabling condition. The EMR will then generate an inaccurate record stating that the patient’s musculoskeletal system and neurological system are within normal limits.
Disability insurance carriers can then use these default settings to their own advantage to raise questions about the severity of the claimed disability, justify an independent medical examination or functional capacity evaluation, or support a claim termination. For patients who are receiving disability benefits, it is therefore important to know what their medical records look like and to effectively communicate with their physicians to ensure that their conditions and symptoms are accurately recorded on each visit.
Beware the “Offset”
Insureds may think that if their disability claim is approved and the insurer begins paying disability benefits, they have won the battle. In reality, however, even the insurer’s complete admission that the insured is disabled within the terms of the policy does not mean that the insurer will pay the full monthly benefit listed in the policy. Most of us think of disability insurance as providing a stream of income to replace lost salary, but few understand that these policies often contain language effectively cutting off other benefits to which the insured would otherwise be entitled.
Disability insurance policies, especially long-term disability policies, frequently contain “offset” provisions, which offset other benefits against the insurer’s monthly payments. Common offsets include benefits which the insured receives from Social Security disability or retirement, unemployment compensation, worker’s compensation, no-fault auto insurance, sick leave, severance pay, and others. The net effect of these offsets is that should the insured receive a benefit from another source, the disability insurance company will reduce its monthly payment by the same amount.
What is an Incontestability Clause? An Arizona Case Study
What is an incontestability clause? An incontestability clause protects you against being denied coverage because of a preexisting condition.
This clause precludes insurance carriers from inquiring into the representations dentists, physicians, and other professionals made on the policy application if the two-year incontestable period has lapsed. In essence, the clause gives insurers a two-year time limit to review policy applications. If the insurance company makes no inquiry in those two years, they lose the ability to rescind the policy based on a preexisting condition.
For example in the case of Robison v. Brotherhood of R. R. Trainmen Ins. Dept.,[1] the plaintiff had been treated for tuberculosis prior to the effective date of the policy. Three years after obtaining the policy he became disabled from tuberculosis. When the insurance company tried to deny the insured’s claim, the Arizona Supreme Court ruled from its bench in Phoenix that the incontestable clause of the contract precluded the insurance company from inquiring about the insured’s health prior to the effective date of the policy.[2]
Second, this clause protects you against an insurance company’s attempt to deny a claim for disability insurance benefits based on a representation you made that is not material. For instance, when filling out the application for the insurance policy, you might write down the wrong year that you had some minor knee surgery. An insurance company cannot use such a miniscule and immaterial mistake to deny you coverage when your claim is for debilitating arthritis in your hands which doesn’t allow you to practice properly in your field of medicine.
Third, this clause protects an insured that is completely truthful when filling out the policy paperwork. In Paul Revere Life Ins. Co. v. Haas the court upheld a policy which limited “coverage to sicknesses that ‘first manifest’ themselves after the policy has been issued.”[3] This means that if you have a condition before the insurer issued the policy, but you don’t become aware of it until after the policy has become effective, the condition should be covered.
It is important to remember that and incontestable clause usually includes a caveat: it does not protect an insured that knowingly or fraudulently misrepresents information during the application process. The Haas court stated that the language of the incontestable clause “does not protect insureds who make fraudulent misrepresentations in their applications. Rather, the language is intended to protect those insureds who are unaware of their diseases.”[4] The insurance company in Haas (Paul Revere, a subsidiary of Unum) was allowed to deny coverage of the insured’s eye condition when the insured knew about and had been treated for the disease well before the start of the policy. The court believed that the legislature did not intend for the mandatory incontestable clause to be “an invitation for fraudulent applications for disability insurance.”[5] The preexisting eye condition was deemed to be a fraudulent misrepresentation, and the insurance company denied its coverage. We also discussed this topic in a previous post entitled “Medical History Misstatements On A Disability Insurance Application Can Void The Policy In The Future.”
The outcomes of the cases based on incontestable clauses show how important it is to be truthful throughout the insurance claim process. The more accurate you are about your health condition, the fewer coverage problems you may have down the road.
If you have questions about your policy’s incontestability provisions, an experienced Arizona disability insurance attorney can help talk you through how they work, and how that could impact your disability insurance claim.
[1] Robison v. Brotherhood of R. R. Trainmen Ins. Dept., 73 Ariz. 352, 241 P.2d 791 (1952), opinion modified on reh’g on other grounds, 74 Ariz. 44, 243 P.2d 472 (1952).
[2] Id.
[3] Paul Revere Life Ins. Co. v. Haas, 137 N.J. 190, 210, 644 A.2d 1098, 1108 (1994).
[4] Id.
Ed Comitz Presenting Course “Disability Insurance: Will It Be There When You Need It?” at Western Regional Dental Convention on Friday April 4 and Saturday April 5, 2014
Attorney Ed Comitz will be giving a presentation called “Disability Insurance: Will It Be There When You Need It? Choosing Policies, Pursuing Benefits and Litigating Claims” on April 4th (Course Code F08) and April 5th (Course Code S06) at 8:30 a.m. at the Western Regional Dental Convention in Phoenix, Arizona. The course is worth three CE credits for dentists who attend. Registration information is available on the Western Regional Dental Convention’s website.
We are also an exhibitor at the dental convention. Please feel free to stop by our Booth 537 (directly across from the Internet Cafe) if you have questions about your disability insurance policy or claim.
How Long Do I Have to Formally File My Claim?
You have finally come to the realization that working through the pain and limitations of your disability is no longer in your best interests. Continuing to work is not an option for you, so you have decided to make a long term disability insurance claim. How long do you have to file your claim? Does it have to be on the day that you become disabled, or can it happen a couple months down the road? The answer to that question is: it depends.
Insurance companies will try and exploit every option available to deny a claim for disability insurance benefits. One method they utilize is to put strict requirements on how and when an insured must give notice to the company of their disability and what that notice must contain.
The first place to start looking to determine your insurance company’s requirements is the insurance policy itself. Look through the policy index or headings for a section similar to “Notice of Claim.” This section lets you know how much time is available to file a disability claim with the company. Continue reading “How Long Do I Have to Formally File My Claim?”
Provident Loses the Battle Over Discovery of Employee Compensation and Bonus Information Tied to the Denial of Insurance Benefits.
In previous posts entitled “Why Is It So Hard To Collect On My Disability Insurance Policy?” and “Does Your Unum Claims Handler Have a Personal Financial Incentive to Deny or Terminate Your Disability Claim?”, we reviewed a leading reason behind insurance companies denying disability insurance claims: claims managers often receive incentives, including bonuses, depending on the amount of money they save the company. For the claims department, saving the company money is frequently achieved by denying the claims of existing customers who are receiving disability insurance benefits. This conflict of interest is a probable basis for denial or termination of many legitimate disability claims.
A recent discovery decision by the United States District Court, N.D. California in Welle v. Provident Life & Accident Ins. Co., 2013 WL 5663221 (N.D. Cal., Oct. 17, 2013) comes as a major win for those with legitimate disability claims. There, Doctor Dana Welle injured her left arm in a bike accident. After multiple surgeries, she was diagnosed with ulnar neuropathy and left medial epicondylitis. This condition gave her pain and weakness in her left arm that impacted her ability to safely care for her patients. After Provident Life Insurance (a Unum company) had paid almost three years of disability insurance benefits to Ms. Welle, the company denied her benefits.[1]
In her suit against Provident, which claimed bad faith denial of her benefits, Dr. Welle alleged that Provident’s “incentive structure was based on performance, and performance may be measured, in terms of resolution of claims, including her own.”[2] Dr. Welle requested Provident to produce “any and all documents that reflect, refer or relate to bonus awards, including but not limited to the performance rating and percent of bonus awarded” to claims managers and claim handlers.[3]
Provident objected to the request because, as they argued, it was overly broad and sought to obtain information that was private, proprietary and confidential. The Court overruled Provident’s objections and allowed the discovery. The Court reasoned that the information she sought in her requests “speaks to whether her claim was improperly denied and whether Provident encourages bad faith practices.”[4]
The Court further reasoned that Dr. Welle had shown compelling need for the documents that related to the bonuses of those involved in adjusting her disability insurance claim, and that the information was “highly relevant to her bad faith claim.”[5] The Court disagreed with Provident’s concern with the request being overly broad because it only requested bonus and performance related information of specific individuals. The Court also disagreed with Provident’s defense that discovering the information would breach the employees’ privacy rights, or that the information was proprietary and confidential, because Dr. Welle had already stipulated to a confidentiality agreement and protective order that covered the entire proceeding.[6]
Thus, the Court allowed discovery of the employees’ bonus and performance related compensation documents. Though this is not the end of Dr. Welle’s fight to receive her legitimate disability insurance benefits, it is a major step in helping her get the ammunition she needs to assure her of future benefits under the policy.
[1] Welle v. Provident Life & Accident Ins. Co., 2013 WL 5663221 (N.D. Cal., Oct. 17, 2013).
[2] Id.
[3] Id.
[4] Id.
[5] Id.
[6] Id.
Physicians and Dentists With Parkinson’s Disease:
The Condition, Its Occupational Impact and Disability
Introduction
Among the most devastating degenerative medical conditions is Parkinson’s disease, which currently affects 6.3 million people worldwide. While certain genetic conditions and environmental triggers may increase susceptibility to the disease, it is impossible to accurately predict who will develop it.
For healthcare professionals (physicians and dentists) diagnosed with Parkinson’s disease, the disease can be career-ending as symptoms become more severe. This post will provide a brief overview of Parkinson’s disease; explain the limitations the condition may create and how this could impact a professional career; and provide a solid base of information for anyone struggling with the prospect or process of filing a disability insurance claim.
Background
Every year, there are approximately 60,000 new diagnoses of Parkinson’s disease, a condition affecting the nervous system, motor control, and brain chemistry. Recent improvements in treatments, including exciting therapies involving “reprogramming” skin cells to behave like stem cells, act as small steps toward a solution, but there is currently no cure for Parkinson’s disease. Sufferers often go undiagnosed for many years, and because of the progressive nature of the illness, it can cause a slow deterioration in ability to function normally in day-to-day life.
Disease Progression
After the initial diagnosis and into early stages of Parkinson’s disease, symptoms may seem manageable and typically include fatigue, tremors, joint pain, and anxiousness.
As the disorder progresses, it is common to experience stiffness, lack of coordination, and slower movement. Everyday tasks such as getting dressed, shaving, writing, and brushing teeth can become strained, and there is a high susceptibility to falls and related injuries due to disturbed sense of balance.
Once Parkinson’s disease reaches advanced stages, affected individuals sometimes lose the ability to walk, speak, and properly care for themselves. Since Parkinson’s disease is a disorder of the nervous system, it can result in chemical changes within the brain, causing individuals to experience symptoms involving disruption of mental clarity, altered judgment, anxiety, or depression. In effort to control challenging symptoms, sufferers often go through the frustrating experience of experimenting with new medications, which can also produce unpleasant side effects.
Medical Professionals Diagnosed with Parkinson’s Disease
It is understandably difficult to grasp the frustrating new limitations that go along with Parkinson’s disease, as symptoms sometimes come and go, progressing gradually over time. Doctors who have been diagnosed with the illness may be tempted to continue practicing as usual, despite their worsening symptoms. Unfortunately, the reality is that the slightest side effect, such as tremor or delayed reaction time could potentially have life-altering consequences for practitioners or their patients. Should a doctor be sued for medical malpractice post-diagnosis, a jury could be convinced that the doctor should not have been practicing due to the nature of the illness, regardless of whether or not it was a factor in the incident. The dichotomy between lifelong work ethic and patient safety is what makes Parkinson’s disease so devastating to physicians and dentists – considering the amount of time, energy, and money invested into a professional career, there is a reasonable hesitancy to take a step back.
When to File a Disability Insurance Claim
Early Parkinson’s disease symptoms mimic other more common ailments, often causing the condition to go undiagnosed for lengthy periods of time; furthering the problem, no one test is able to confirm a diagnosis of Parkinson’s disease. Individuals undergoing the diagnosis process frequently experience a trial-and-error scenario, and symptom improvement with specific medications is often the litmus test for whether or not a person truly has the disease. These factors make it very difficult to determine when a disability insurance claim should be filed – when filed too soon, there may not be substantive proof of disability, but waiting too long could leave a practitioner exposed to liability.
A common mistake for sufferers of Parkinson’s disease is the attempt to modify work schedules and regular work duties with the progression of symptoms. Despite the fact that these measures are taken to avoid the risk of injury to the affected doctors or to their patients, the impact of this decision on future disability claims is substantial. A practitioner will typically perform fewer procedures, take on more management duties, and scale back hours over a period of time until working is no longer an option. The modification of one’s scope of practice and work hours can make it extraordinarily difficult, if not impossible, to collect future disability benefits, as insurance companies define a practitioner’s occupation (and ability to receive benefits) based on the work done at the time he or she becomes totally disabled. In short, this means that as one modifies his or her duties and hours, he or she is modifying both position and capability in the eyes of a disability insurance company to something less than that of a full time clinical practitioner. Keeping this in mind, it is best to explore the possibility of filing a total disability insurance claim as soon as possible after diagnosis, and it is prudent to speak with an attorney who is well-versed in filing disability claims.
Summary
Parkinson’s disease has had a personal impact on the lives of our staff, and we are no strangers to how difficult it can be to deal with long-term medical issues. Perhaps the most important step in accepting and understanding Parkinson’s disease is taking the time to get the help you need. Seek the support of family, friends, and professionals to help you cope with the changes ahead.
Additionally, understand that knowledge is power. Parkinson’s disease can have a major impact on finances, relationships, work, time, and various other aspects of daily life. Educating yourself about the future and what to expect, including when to file a disability insurance claim, will help you to feel more prepared and able to face challenges as they arise.
