When filing a claim, many dentists and doctors think that they will merely have to submit a form giving notice of the claim and have their doctor sign something verifying they are disabled. Most don’t realize or expect the breadth of their insurance company’s investigation and one thing that often surprises dentists and physicians is the company’s request for their CPT or CDT codes. Most newer insurance policies contain language that expressly allows insurers to request financial and practice information like this, and there are several things they are looking at when they request these codes.
Changes to Your Occupation/Job Duties
Most own occupation policies say they will consider you to be totally disabled if you can no longer do the “material and substantial” duties of your occupation. Insurance companies will look to CDT/CPT codes to see if you have changed or limited the types of procedures you do, and thus potentially modified your job description, prior to filing the disability.
When you file a claim, the company will typically be looking at what your duties were immediately prior to your reported date of disability. If you stopped performing more difficult procedures for an extended period prior to your date of disability, many companies will try to narrowly define your occupational duties as something less than what you perceive your occupation to be. For example, they might characterize you as a “dentist who doesn’t do root canals,” or a “surgeon who doesn’t do hip surgeries.”
Changes in Hours/Production
Similarly, reducing your work hours prior to filing a claim can impact your ability to collect. While your CDT/CPT codes won’t necessarily directly show the hours and days worked, they will show drops/increases in production and prompt follow-up questions from the insurance company if the production numbers don’t add up.
Additionally, some policies require an insured to work a certain number of hours a week, and cutting back on hours for an extended period of time prior to filing a claim could also lead your insurance company to classify your occupation as “part-time.” This is problematic because it becomes much harder to prove you can’t work part-time, versus proving you can’t work full-time.
Reviewing and understanding your policy, including what types of information your insurance company will request, is an important part of any transition plan. If you are considering filing a disability claim, you should consult with an experienced disability insurance attorney to learn more about your policy and any potential issues related to your particular claim.
In prior posts, we’ve discussed the mental health challenges physicians and dentists can face due to their high-stress and high-responsibility work environments. We often see doctors who are wondering if they can successfully file a claim based on a mental health condition, but are also reluctant to ask because they are concerned about what their colleagues/families/friends with think. Often, they feel like they are the only one struggling with these challenges but, in reality, they are not alone.
Unum, one of the largest disability insurers in the U.S., recently released a report that looks at mental health challenges in the U.S. workplace. The report found that mental illness was one of the top causes of worker disability in the United States, with 62 percent of missed work days attributable to mental health conditions. Of those employees with mental health conditions:
- Forty-six percent of those who missed work took an extended period of time off (over a week)
- Two-thirds of employees with mental health issues went to work while experiencing symptoms (and reported a drop in productivity)
- Forty-two percent of those who came to work were experiencing suicidal feelings
Despite the prevalence of mental health conditions (including anxiety, depression, and PTSD), sixty-one percent of the surveyed employees indicated that they felt there was a social stigma around those with mental health issues.
Although this study looked at data from employees, human resource professionals, mental health professionals, and research organizations that was not specific to the medical field, it is widely accepted that doctors are among those most likely to experience burnout during the course of their careers, with symptoms that overlap those of depression, anxiety disorder(s), and/or other mental health conditions. Unfortunately, stigma in the workplace and presenteeism may make doctors even more likely to ignore the symptoms of a mental health condition, push themselves to keep working, and/or avoid seeking support on the job and/or through treatment.
Ironically, we often see Unum (and other insurance companies) target mental health claims made by professionals due to the higher benefit amount of their policies and the more subjective nature of symptoms related to mental health conditions. They may pressure your treating provider for a return to work date, conduct surveillance to catch you in a happy moment that can be taken out of context, or have their in-house doctor question your course of treatment.
Further, many disability insurance policies now have substance abuse and mental health limitations provisions, which limit the amount of time a policyholder can collect for these types of conditions (usually to 24 months). For these reasons, it is very important for physicians, dentists, and other professionals to have an awarenes of the challenges that may arise when filing a claim and understand what their policy says.
If you are considering filing a disability claim based on a mental health condition, you should consult with an experienced disability insurance attorney to learn more about your policy and any potential issues related to your particular claim.
 Unum report explores mental health challenges in U.S. workplaces, Unum, March 27, 2019.
Disability claims filed by professionals can be complex, particularly when the dentist or physician’s underlying occupation is a specialty specific field.
If the claim involves a discrete practice area, disability insurers may use that as an excuse to drag their feet when making a claims decision. For example, they may make repeated requests for employer questionnaires, financial information and/or vocational examinations, among other things. Then, as time goes on, the financial pressures of being left with no income build, prompting some doctors to consider a return to work even though it’s not safe for them to be practicing on patients. Other doctors with specialty-specific policies reason that they can return to work in a different field and expect to receive their benefits as a supplement to the new job, only to find that their insurer disagrees that they were, in fact, a specialist, and refuses to pay total disability benefits.
This is what happened to Joanne Ceimo, M.D., a former invasive cardiologist from Scottsdale, Arizona who practiced at Banner Boswell Medical Center in Sun City, Arizona. Dr. Ceimo had an own occupation policy and was practicing within her medically recognized specialty of invasive cardiology. In 1994, doctors diagnosed Dr. Ceimo with cervical degenerative disc disease, which made it increasingly difficult for her to perform surgeries and prevented her from performing on call duties. Eventually, she was forced to stop performing surgeries as well and instead began practicing general cardiology.
In her mind, Dr. Ceimo’s new job as a general cardiologist was substantially different than her prior job as an invasive cardiologist. However, Dr. Ceimo ultimately had to sue General American, along with Paul Revere and Provident (the other insurance companies administering her claim) for the benefits she was due under her policy. She filed her disability insurance claim in 1995 and, after a long, drawn-out claim investigation, was eventually denied benefits in 1998. Due to the long delay, Dr. Ceimo was forced to continue working as a general cardiologist to meet her expenses, even though it was bad for her health and working made her pain worse.
When they denied her claim, the companies asserted that Dr. Ceimo was not a specialty cardiologist because she had only spent six to ten hours on surgeries per week. The companies then stated that her occupation before her date of disability was that of a general cardiologist, and concluded she was not eligible for total disability benefits because she continued to practice in that capacity. In making this argument, the companies ignored the fact that Dr. Ceimo had practiced invasive cardiology from when she was licensed by the Arizona Medical Board in 1982 through the onset of her disability in 1995. The companies also failed to mention that their own medical records review classified Dr. Ceimo as an “invasive cardiologist.”
Dr. Ceimo and her lawyers filed a bad faith lawsuit in the District of Arizona against General American, Paul Revere and Provident. In addition to arguing that the companies improperly interpreted her specialty, Dr. Ceimo and her attorneys also asserted that the companies improperly relied on biased in-house medical consultants and internal company practices geared towards denying high-dollar physician claims like Dr. Ceimo’s. The case ultimately produced a large verdict in favor of Dr. Ceimo, with almost $6.7 million in consequential damages, but it took nearly a decade of fighting before she obtained the benefits she was due under her policy.
Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your company is improperly delaying a claims determination and/or targeting your claim for denial or termination, an experienced disability insurance attorney can help you assess your claim and determine what action, if any, needs to be taken.
 See Ceimo v. Gen. Am. Life Ins. Co., 2003 WL 25481095 (D. Ariz. Sept. 17, 2003).
While the difference between an injury and sickness may, initially, seem clear-cut, if you have certain disabling conditions (such as degenerative disc disease or carpal tunnel syndrome) whether you have a disabling sickness versus injury can be a very nuanced determination. For example, when a particular event causes a slowly progressive disease to become suddenly disabling to the point a dentist or doctor can no longer work in his or her occupation, the final determination may have to be made by a court.
This is what happened in a recent case before the Arizona District Court. Dr. Wood was an anesthesiologist who practiced in Page, Arizona within the Banner health system. Dr. Wood suffered from degenerative disc disease in his lumbar and cervical spine, but continued to practice (a common phenomenon among physicians and dentists called presenteeism). In 2015, he and a team of nurses lifted a patient from the operating table to a hospital bed—a routine maneuver that he had done thousands of times before. This time, however, the maneuver resulted in intense radiating pain in his spine and he found himself unable to work. Dr. Wood then filed a claim with his insurer, Provident, due to the disabling back condition.
While Dr. Wood felt his disability was caused by an accident, making him eligible for lifetime benefits under the terms of his policy, Provident classified his disability as a result of sickness, and maintained he was only eligible for 48 months of benefits. Dr. Wood sued Provident and the court had to determine what “injury” meant.
Fortunately for Dr. Wood, in this case, the Arizona judge determined that the policy had a vague definition of “injury” and ruled the provision should be interpreted in Dr. Wood’s favor. The court turned to precedent set by the Arizona Court of Appeals, finding that Arizona does not distinguish between ‘accidental means’ and ‘accidental results.’” The court also noted the Arizona Supreme Court’s findings that “accident” must be read in light of common speech, usage, and understanding of the average man. In the end, the court found that, under Arizona law, Dr. Wood became disabled when performing the lifting maneuver and he was eligible receive lifetime benefits.
Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are unsure of how your policy interprets sickness versus injury, an experienced disability insurance attorney can help you interpret this language and apply it to your particular situation.
 See Wood v. Provident Life & Accident Ins. Co., 2018 WL 2416190 (D. Ariz. May 29, 2018).
 Id. quoting Central Nat. Life Ins. Co. v. Peterson, 529. P.2d 1213 (Ariz. App. 1975).
 Id. quoting Knight v. Metro Life Ins. Co., 437 P.2d 416 (Ariz. 1968).
An independent medical exam (“IME”) is an exam conducted by a doctor to verify whether you are truly disabled under your disability insurance policy’s terms. These IMEs are rarely “independent”, and the doctors conducting them are almost always selected and paid by the insurers. In this post, we will explain what you can expect during an IME, and how you can protect yourself during the IME process.
What Can I Expect During an IME?
The IME doctor will likely begin by conducting an interview to learn about your medical history, the nature of your job, your symptoms, your treatment to date, and your daily activities. During the interview, the doctor will be looking for signs that you are not telling the truth or that you are exaggerating your symptoms and limitations. The doctor will pay attention to your demeanor, body language, and general appearance in order to assess your credibility. The doctor will also compare your reported symptoms and limitations to your medical records, claim forms, and daily activities in an attempt to find inconsistencies.
Typically, the IME will largely consist of a physical examination, and the doctor may also require objective testing, such as x-rays, MRIs, or EMGs. The doctor will often begin by conducting a general checkup, taking height/weight measurements, listening to your heart and lungs, testing your blood pressure, etc. The doctor may then perform tests that focus on your disability and require you to provide subjective indications of pain and discomfort. He or she may ask you to bend, lift, or perform simple physical movements, depending on the nature and location of your condition. Again, the doctor will be looking for inconsistencies or any signs that you might be exaggerating your symptoms.
After the IME, the doctor will complete a report that summarizes the findings of the exam. The doctor will opine as to the extent of your disability, your ability to return to work, and recommended treatment or further testing.
How Can I Protect Myself in the IME Process?
As explained above, IMEs can be used as a tool for the insurance companies to deny or terminate disability benefits. Fortunately, there are ways you can protect yourself and ensure that you are treated fairly before, during, and after the IME.
Before the IME:
- Review your policy. Most insurance policies do have a provision that allows the company to require you to submit to a physical exam. However, these provisions are sometimes unclear as to the exact type examinations that are allowed. Review the terms of your policy to make sure that your insurer can require you to undergo an IME.
- Complete intake forms in advance. Your doctor will most likely ask you to complete intake forms, including questionnaires that outline your symptoms and medical history. If you are nervous or hurried, you may forget to include important information. Filling out the forms in advance allows you to answer each question carefully and accurately.
During the IME:
- Bring a friend. If possible, bring a friend or family member to the IME. Not only can your friend provide moral support, but they will also serve as a witness to the exam.
- Take notes. If possible, take notes during the IME to remember what testing was performed or what types of questions were asked. When you leave, write down your impressions and any issues you think you need to follow-up on.
- Be cooperative and open. Be patient and polite with the doctor. Answer questions in a straight-forward and truthful manner, and if you do not understand something, let the doctor know. While you should be cooperative, this does not mean you need to do anything that causes you pain or injury. You know your body and limitations best, so if something the doctor asks you to do will cause you pain, let him or her know.
- Discuss your symptoms fully and honestly. Do not minimize your symptoms and do not be afraid to complain. It is important that your pain levels and other symptoms are documented as accurately and thoroughly as possible.
- Connect your symptoms to your job duties. Make sure you discuss how all of your conditions impact your ability to practice safely and effectively. Give specific examples of how the conditions interfere with your practice (e.g., you cannot sit or stand for long periods without pain; you cannot manipulate dental instruments due to numbness in the fingers, etc.).
After the IME:
- Get a copy of the report. After the exam, contact your insurer to ask for a copy of the IME report. Review the report and compare it to your notes and recollection of the IME. If anything needs to be clarified or there are any inconsistencies, contact your attorney and/or disability insurer as soon as possible.
If you have been scheduled for an IME, you may want to get an experienced disability insurance attorney involved. An attorney can protect your rights during the IME process by finding out what the disability policy requires, limiting the test to certain parameters, studying the examiner’s credentials, recording the exam, accompanying you to the exam, and reviewing the final report for accuracy.
It’s no secret that dentistry is hard work, requiring concentration, precision, visual acuity, depth perception, and quick reaction time if there is an emergency situation . In prior posts, we have discussed how, as a result of these demands of the profession, musculoskeletal conditions are all too common in dentists, and often lead to dentists needing to file disability insurance claims. Similarly, a dentist who undergoes changes to his or her vision, whether via injury or disease, faces the very real possibility that he or she may need to step away from practicing dentistry early. In fact, one study showed that sight disorders were the second most common reason dentists asked for help (34.7% in females, 32% in males), and the same study showed that sight disorders were recorded in 45.7% of the female dentists participating in the study and 48.5% of the male dentists, with eye injuries being the most common reported reason for seeking help.
Some eyesight injuries/impairments experienced by dentists may occur on the job, through physical hazards (radiation, artificial light) or chemical hazards (dental materials, including amalgam and dental cement particles, equipment, disinfectant, etc.). Diseases of the eye are also not uncommon as one ages, and older dentists may find it increasingly challenging to effectively practice when faced with an eye disease, especially during procedures that require a significant degree of hand-eye coordination (e.g. root canals, crown procedures, etc.).
Some of the most common eye conditions in adults include age-related macular degeneration, cataracts, central retinal vein occlusion, retinopathy (due to diabetes), macular edema, glaucoma, and retinal tears and detachments. Many of these conditions can cause symptoms that can limit a dentist’s ability to practice safely and effectively (e.g. blurred vision, floaters, halos around lights, double vision, difficultly seeing in low or bright light, etc.), and over times some can even result in partial or total blindness. In addition, there are several lesser-known genetic eye conditions that can have equally devastating effects on a dentist’s ability to safely practice, including retinitis pigmentosa, choroideremia, Best disease, and cone rod dystrophy, among others.
Whether sight impairment and/or vision loss occurs through a common or rare disorder, vision problems are often slowly degenerative and progressive. In some instances, there may be ways to acceptably compensate for the vision impairment, whereas in other instances the impairment can be severe enough that it is obviously disabling. However, like other slowly progressive conditions, there is often a significant gray area between these two extremes that can be difficult to navigate if you do not have an understanding of how the disability claims process works. Dentists facing a progressive eye condition must carefully (and constantly) balance the need to keep their practice running, support their families, and continue the job they love against their duty to keep their patients safe and the risks of board complaints and/or malpractice lawsuits.
As a result, we’ve often seen dentists try to continue working even after a serious diagnosis by reducing their hours and/or the types of procedures they perform; however, doing so can hurt your chances to collect under a future disability claim, as this can undercut the severity of a claim and re-define the job duties, potentially making it much harder to establish total disability under the terms of your policy. Because of this, if you are a dentist with an eye condition that could potentially be disabling in the future, it is a good idea to have someone who is familiar with the claims process (like an experienced disability insurance attorney) evaluate your situation and start preparing a transition plan so that, if things progress to the point where you do have to file a claim, you are prepared.
These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described above and have yet to consult with a physician do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.
Mayo Clinic, www.mayoclinic.org
National Eye Institute, https://nei.nih.gov
U.S. National Library of Medicine, https://ghr.nlm.nih.gov
Retina International, http://www.retina-international.org
American Academy of Ophthalmology, https://www.aao.org
American Society of Retina Specialists, https://www.asrs.org
 Dhanya Muralidharan, Nusrath Fareed, & M. Shanthi, Musculoskeletal Disorders among Dental Practitioners: Does It Affect Practice?, Epidemiology Research International, Vol. 2013, Article ID 716897 (2013)
 Marin Vodanovic, Slavica Sovic, & Ivan Galic, Occupational Health Problems and Dentists in Croatia, Acta Stomatol Croat., 2016 Dec; 50(4): 310-320
As a dentist, you probably have purchased at least one disability insurance policy, and you probably sought out “own occupation” coverage. However, in our experience, many dentists do not understand what their policy actually says or realize that there are several variations of “own occupation” policies. Additionally, many of the newer disability policies being sold to dentists have particular requirements and “rules” that must be followed in order to qualify for benefits.
Our latest article with Dentaltown Magazine discusses some of these pitfalls and explains why it is important to know what your policy says before filing a claim. Read the full article at Dentaltown today.
In an ideal world, you’d receive a favorable decision and your first benefit check shortly after your disability insurance policy’s elimination period is satisfied. Unfortunately, even wholly legitimate disability claims get scrutinized, questioned, delayed, and in some cases, denied. Below are a few common reasons disability benefit payments are delayed, particularly at the outset of a disability claim.
Improperly Completed/Partially Completed Forms
If your initial claim forms are missing information, unreadable, or incomplete, your disability insurer will likely issue additional forms for completion or use the missing information as an excuse to delay processing the disability claim. This applies to both the forms that you are required to complete and sign and the forms the insurer gives you to give to your doctor to fill out, so it is important to follow up with your doctor and make sure that all of the necessary forms are completed and returned in a timely fashion. If you do not carefully document your disability claim, and you do not promptly respond to requests for follow-up information, most insurers will delay making a claim decision until you provide them with the requested information.
Pending Requests for Information
At the outset of your disability insurance claim, your insurer will require you to sign an authorization that allows them to request a wide range of information from a wide range of sources, including your doctors and employer. Oftentimes, the insurer will request information from these other sources (without telling you) and then will delay making a decision on your disability claim if any of these requests remain pending.
This means that even if you provide the insurance company with everything they requested from you, there may be other information that the company is waiting that is holding up the claims decision. Consequently, it’s important to ask the insurance company to find out if there are any pending requests, adn then follow up with your doctors, employers, etc. as needed to ensure that the information is provided.
It’s also important to keep tabs on the pending requests, to determine whether the scope of the disability insurer’s investigation is appropriate. An experienced disability attorney can advise you on whether a particular request for information is warranted under the circumstances of your particular claim.
Failure to Schedule Medical Examinations/Interviews
When you file a disability claim, insurers will almost always require that you participate in a detailed interview and/or undergo an independent medical examination (IME). While the stated point of these requests is to confirm or verify your disability, they can often be an attempt by your insurer to discredit your own doctor or medical records and generate fodder to deny your disability claim. Depending on the nature of your condition, your disability insurer might also request other types of interviews or exams—such as a functional capacity evaluation (FCE) or neuropsychological evaluation.
Some claimants (mistakenly) believe that if they keep putting off these exams, then they’ll be able to avoid the exams. However, most disability policies contain a provision that expressly requires the policyholder to submit to exams, and states that failure to do so is grounds for denying a claim or terminating disability benefits. So if you put off these exams, it’s only going to delay the company’s claim decision, and possibly result in a claim denial. However, keep in mind that going into a medical examination, IME, or interview unprepared can be just as bad for your claim, so it’s very important to prepare beforehand. Once again, an experienced disability attorney can advise you regarding the proper scope of an interview or IME, and can also be present for the interview or IME, if desired.
You’ve made the difficult decision to give up practicing medicine or dentistry and file a disability claim. You’re not working and you need to collect the disability benefits you’ve likely paid years of high premiums for. So how long will you have to wait until your first benefit check arrives?
Unfortunately, the answer is not clear cut—it depends on the terms of your disability insurance policy, your insurance company, the assigned benefits analyst, and the complexity of your disability claim, among other things.
Filing a Claim
Your disability insurance policy should outline the requirements for filing a disability claim. Typically, you must give notice of your disability claim to your insurer within a certain time frame. If you miss this important deadline, the insurance company will typically claim that you have prejudiced its ability to investigate your claim, and use this as an excuse to delay making a decision on your disability claim. Significantly, if you don’t provide timely notice, it can also foreclose your ability to collect disability benefits (depending on the circumstances, and the reason for the delay).
Once you file your disability claim with your insurer, they will then send disability claim forms to be completed by you and your physician. Your policy should include a deadline for when your insurer must provide you with these forms (e.g. 15 days). If they don’t provide you with forms within this time frame, most disability insurance policies allow you to submit a written statement documenting your proof of loss, in lieu of the forms. Again, there is a deadline to return these forms and failing to do so gives your disability insurer an excuse to prolong the decision-making process.
Elimination and Accumulation Periods
Your disability insurance policy will also contain details about your elimination period. This is the period of time that must pass between your disability date and eligibility for payment on a disability claim. Generally, you must be disabled (as defined in your policy) and not working in your occupation during this time period.
Depending on the terms of your disability insurance policy, this period does not necessarily have to be consecutive, but it does need to occur within the accumulation period also set out in your policy (for example, your policy might require a 90 day elimination period that must be met within a 7 month accumulation period). You will not be eligible for payment until the elimination period has been fulfilled. Typically, disability insurers won’t provide you with a claim decision until after this date has passed.
It is important to be aware of your elimination period, so that you can plan accordingly (and are not expecting a benefit payment to arrive right way when you are budgeting to meet living expenses, or debts like student loans). Also, it’s important to keep in mind that receiving a benefit payment immediately following the elimination period is the ideal scenario. In many disability claims, it takes much longer for a benefit to be issued. In our next post, we will address some of the most common reasons disability benefit payments are delayed.
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.
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 attorney can review your policy and explain your rights and obligations under your particular policy.
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:
- 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.
Disability insurance companies are constantly searching for new ways to expand the power and control they have over their policyholders through the use of restrictive policy provisions. In previous posts we’ve discussed how disability insurers are expanding their control over their policyholders’ medical treatment by implementing more stringent care provisions. However, care provisions are not the only avenue for disability insurers to exert a greater degree of influence in the claims process. Over the years, disability insurers have also expanded the scope of their authority under examination provisions.
The most basic examination provisions simply notify the policyholder that he or she may be examined by the insurer’s doctor or interviewed by a representative of the insurer, like this policy from Northwestern Mutual:
- Medical Examination. The Company may have the Insured examined by a health care practitioner.
- Personal Interview. The Company may conduct a personal interview of the Insured.
- Financial Examination. The Company may have the financial records of the Insured or the Owner examined.
Taken alone, this does not seem to onerous. However, you need to watch out for additional requirements buried at the end of the provision:
Any examination or interview will be performed:
- At the Company’s expense;
- By a health care practitioner, interviewer or financial examiner of the Company’s choice; and
- As often as is reasonably necessary in connection with a claim.
The final sentence of this provision leaves the open the possibility of multiple interviews throughout the claim, and may be overlooked by a claimant who does not carefully review his or her disability insurance policy.
Other provisions, like this medical examination provision from a Standard Insurance Company individual disability insurance policy, expressly condition the payment of disability benefits on your cooperation with the exam:
MEDICAL EXAM – We can have Physicians or vocational specialists examine You, at Our expense, as often as reasonably necessary while You claim to be Disabled. Any such examination will be conducted by one or more Physicians or vocational specialists We choose. We may defer or suspend payment of benefits if you fail to attend an examination or fail to cooperate with the person conducting the examination. Benefits may be resumed, provided that the required examination occurs within a reasonable time and benefits are otherwise payable.
In newer policies the language used by the disability insurance companies has become ever more burdensome. For instance, some modern provisions for examinations and interviews create far more specific duties for the policyholder and condition the payment of disability benefits on the claimant’s satisfaction of these duties. Take this Guardian policy, for example, which outlines the policyholder’s duties and obligations to comply with examinations and interviews in very specific language:
We have the right to have You examined at Our expense and as often as We may reasonably require to determine Your eligibility for benefits under the Policy as part of Proof of Loss. We reserve the right to select the examiner. The examiner will be a specialist appropriate to the assessment of Your claim.
The examinations may include but are not limited to medical examinations, functional capacity examinations, psychiatric examinations, vocational evaluations, rehabilitation evaluations, and occupational analyses. Such examinations may include any related tests that are reasonably necessary to the performance of the examination. We will pay for the examination. We may deny or suspend benefits under the Policy if You fail to attend an examination or fail to cooperate with the examiner.
You must meet with Our representative for a personal interview or review of records at such time and place, and as frequently as We reasonably require. Upon Our request, You must provide appropriate documentation.
Examination provisions containing language this specific and this restrictive significantly limit your rights. The most significant change in the evolution of the examination provision is the number of obligations upon which your benefits are conditioned. This policy language allows disability insurers to use your benefits as leverage to compel your compliance with medical exams, interviews, and a litany of other examinations.
Review your disability insurance policy, and particularly your examination provisions in the “Claims” section, to determine what your rights, duties, and obligations are under your policy. Unfortunately, if your disability insurance policy requires to participate in examinations, a refusal will likely lead to a denial of benefits. However, you do not have to attend alone. No matter how restrictive the language in your disability insurance policy, you always have the right to have an attorney present for any examination or interview. If you have any questions about your duties or obligations under your disability insurance policy, contact an experienced disability insurance attorney.
Your maximum benefit period is one of the most important provisions in your disability insurance policy. Its terms control the period of time during which you are eligible to receive disability benefits under your policy.
Oftentimes the maximum benefit period is more complicated than you may expect. For instance, most newer disability policies contain a benefit schedule that details the length of your benefit period more precisely, based upon your age at the time the claim is filed. This policy from MetLife contains a maximum benefit period schedule similar to those found in many disability insurance policies:
Table A. Maximum Benefit Period Varies By Age When Disability Begins
Age When Disability Begins Maximum Benefit Period
Before Age 61 To Age 65
At Age 61, before Age 62 48 Months
At Age 62, before Age 63 42 Months
At Age 63, before Age 64 36 Months
At Age 64, before Age 65 30 Months
At Age 65, before Age 75 24 Months
At or after Age 75 12 Months
As you can see, under this sort of provision, the maximum benefit period is reduced based upon how old you are when your disability begins.
It is important be aware that all of the relevant information for determining your maximum benefits period is not always located in the same part of your disability insurance policy. For example, your policy summary may contain an asterisk and then, in fine print at the bottom of the schedule state something like “*The Maximum Benefit Period may change due to your age at total disability. Please see Policy Schedule II.” Then, if you notice the fine print and turn to Schedule II, you see something similar to the MetLife schedule, above, that limits the benefit period based upon your age at the onset of disability.
Other disability insurance policies require a bit more calculation. For example, policies like this one from Mutual of Omaha take your Social Security Normal Retirement Age into account:
61 or less: to Age 65 or to Your Social Security Normal Retirement Age, or 3 years and 6 months, whichever is longer
62: to Your Social Security Normal Retirement Age or 3 years and six months, whichever is longer
63: to Your Social Security Normal Retirement Age or 3 years, whichever is longer
64: to Your Social Security Normal Retirement Age or 2 years and 6 months, whichever is longer
65: 2 years
66: 1 year and 9 months
67: 1 year and 6 months
68: 1 year and 3 months
69 or older: 1 year
If your policy contains a provision like this, you can use this calculator to determine your Normal Retirement Age, to determine exactly how long you are entitled to disability benefits.
Finally, it is important to note that many disability insurance policies have specific, limited benefit periods for certain conditions such as mental illness and substance abuse (and typically restrict coverage for these sorts of conditions to a short time frame—usually 1 or 2 years).
As you can see, the maximum benefit provision can take many different forms in a disability insurance policy. It is critical that you read your policy carefully and have a firm grasp on how your maximum benefit period provision affects your eligibility for disability benefits. If you have any questions about your disability insurance policy, contact an experienced disability insurance attorney.