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.
In previous posts, we have discussed the importance of properly documenting your disability. In this post we are going to discuss one way you can document your disability—pain journals.
A pain journal is exactly what is sounds like—a journal in which you document your pain levels and symptoms each day. Creating this sort of record will not only provide you with documentation when filing your disability claim, but will also allow you to effectively communicate with your treatment providers regarding your symptoms, so that they can provide you with appropriate care. Oftentimes, depending on your disability, you will go several days or weeks without speaking to your treatment providers. A pain journal can help you easily recall and communicate to your treatment provider everything that has happened since you last met with them.
Tips for Creating a Pain Journal
When creating a pain journal, you want to be as specific as possible so that your record is complete. You also want to make sure that you describe your plain clearly, so that you will be able to understand what you meant when you refer back to your journal.
Here are a few things you might consider documenting in your journal:
- The location of the pain.
- The level of the pain (if you use a numeric scale, be sure to also describe the scale).
- The duration of the pain.
- Any triggers to the pain.
- Any medications you are taking.
- Whether the medications you are taking are effective or have any adverse side effects.
- Any other symptoms in addition to the pain.
When filling out your pain journal, you may have a hard time coming up with a description that fits the type of pain you are experiencing, since all pain is not the same. However, you should avoid the temptation to document your pain in a generic way. The type of pain you are experiencing is just as important as your pain levels, and it is something that your disability insurer will likely ask you to describe.
To that end, here is a list of adjectives that are commonly used to describe pain:
Cutting; Burning; Cramps; Knots; Deep; Pulsing; Sharp; Shooting; Tender; Tight; Surface; Throbbing; Acute; Agonizing; Chronic; Dull; Gnawing; Inflamed; Raw; Severe; Stabbing; Stiff; Stinging
Sample Pain Journals:
American Pain Foundation Form:
American Cancer Society Form:
Peace Health Medical Group Form:
In this post, we are going to discuss the four functions of an insurance company.
Introduction – The Promise
Insurance is not like any other business. Rather than selling a tangible product that you receive immediately upon paying for it, insurance companies are selling an important promise—a promise of protection, security and peace of mind if something goes wrong.
When you buy a car, you give someone money and you take a car home. When you buy groceries, you pay money and get your groceries. Insurance is different. With insurance, you give them money and trust, and hope and pray that you never have to collect.
The Four Functions of Insurance
The activities of an insurance company can be divided into four major functions:
The actuarial department is concerned with what kind of promise the company is going to sell and how much the promise should cost. Essentially, the actuaries’ role is to analyze the financial consequences of risk and price the company’s product in a way that will allow the company to make a profit. For example, an actuary working for a car insurance company might calculate the risk that potential customers will be in a car accident, and then adjust premium amounts to account for that risk so that the insurer can pay accident claims and still make money.
The marketing department is concerned with how to get people to buy the promise being sold. They design ads and employ sales people. Basically, this department’s goal is to get people interested in buying the promise.
The underwriting department determines who the company should sell the promise to. Underwriters review applications and assess whether the company should allow applicants to purchase the promise. For example, the underwriting department of a life insurance company might review health questionnaires submitted by applicants to assess whether the level of risk is low enough to provide life insurance to the applicant.
The claims department’s role is to process and pay legitimate claims. While the first three departments are very much concerned about profitability, the claims department is not supposed to consider company profitability when adjusting a claim. If the actuaries made a mistake and sold a product that is costing the company too much money, the product was not marketed correctly, or if underwriting was too lax, the company is supposed to pay legitimate claims and bear the loss.
As we have discussed in previous posts, an insurance company has a legal obligation to treat its customers fairly and deal with its customers in good faith. Ideally, the disability insurance claim process should be simple. You should inform the company that you meet the standards of the contract, provide certification from a doctor of that fact, and collect your disability benefits. It is not supposed to be an adversarial process.
Unfortunately, in instances where one or all of the first three departments mess up, some insurance companies improperly shift the burden of making a profit onto the claims department. This, in turn, transforms the claims process into an adversarial process.
If you have an experienced disability attorney involved from the outset of your disability claim, your attorney can monitor the insurance company to make sure that they are complying with their legal obligations. If you have already filed a disability claim, but believe that your insurer is not properly processing your claim, an experienced attorney can review the insurer’s conduct and determine whether the disability insurer is acting in bad faith.
In Part 1, we looked at how disability insurance companies broadly define mental disorders and substance abuse. In this post, we will be looking at a sample mental disorder and substance abuse limitation provision.
What Does a Mental Disorder and Substance Abuse Limitation Look Like?
Here is a sample limitation provision from an actual disability policy (this provision is taken from the same policy containing the definition of “mental disorders and/or substance abuse disorders” discussed in Part 1):
maximum indemnity period means the maximum length of time for which benefits are to be paid during any period of total disability (see the Policy Schedule on Page 1). Benefits will not be paid beyond the policy anniversary that falls on or most nearly after your sixty-seventh birthday, or for 24 months, if longer, except as provided by this policy. In addition to any limitations described above, the maximum indemnity period for a disability due to a mental disorder and/or substance abuse disorder is also subject to the following limitations: (a) The lifetime maximum indemnity period is 24 months; (b) the 24-month limitation also applies to all supplementary benefits payable by virtue of your disability due to a mental disorder and/or substance abuse disorder; (c) any month in which benefits are paid for a mental disorder and/or substance abuse disorder (regardless of whether paid under the base policy any supplementary benefits or both) shall count toward the 24-month limitation; (d) this limitation applies to this policy and all supplementary benefits under this policy.
Note that this provision is not entitled “mental disorder limitation” or “substance abuse limitation.” Instead, it is entitled “maximum indemnity period.” In fact, this provision is actually part of the policy’s definition section, and not the main part of the policy—highlighting the importance of carefully reviewing the definitions in your disability insurance policy.
Note also that this particular provision provides that any month in which disability benefits are paid counts against the 24 month limit. So, for example, if you received disability benefits for a period of 12 months in connection with a substance abuse related disability, and subsequently returned to work, the next time you needed to file a claim related to a mental disorder or substance abuse, you could only receive a maximum of 12 months of disability benefits.
When purchasing a disability policy, watch out for mental disorder and substance abuse exclusions and limitations. Always be sure to ready your policy carefully so that you understand the scope of the protection you are purchasing. If you already have a disability policy, an experienced disability insurance attorney can review your policy and determine whether it contains any mental disorder or substance abuse limitations that might limit your ability to collect disability benefits under your policy.