Great-West/Protective Disability Claim Tips for Dentists
Our law firm has extensive experience with handling Great-West/Protective disability claims for dentists. Our attorneys understand how Great-West/Protective operates and what it takes to file a successful Great-West/Protective disability claim. If you would like to hear what other dentists have to say about us and see why our law firm is the best option for dentists filing disability claims, please visit our testimonials page.
Below are some answers to the most common questions our attorneys receive from dentists about the disability claim process, generally, and their Great-West/Protective disability benefits, specifically. If you’d like to discuss your particular claim with our attorneys, we are happy to set up a free consultation.
Table of Contents
1. I am a dentist who signed up for the Great-West ADA disability policy; why is Protective handling my disability claim?
In 2019, Protective Life Insurance Company acquired via reinsurance substantially all of Great-West Life & Annuity Insurance Company’s individual life and annuity businesses. Following the sale, Great-West retained a block of policies, including the ADA member Insurance Plans, but Protective Life Insurance Company began to administer disability claims filed by dentists under the ADA policy.
Eventually, Great-West was entirely phased out and Protective also took over the ADA policy itself. So, even though Great-West may be listed on the insurer on prior policy documents or correspondence, all claim decisions are now made by Protective.
2. What qualifies as “disabled” under the Great-West/Protective policy? Does Great-West offer true own occupation disability policies to dentists?
Yes, for now. The policies currently sold by Great-West/Protective to dentists are “true own occupation” policies that allow you to work in a different capacity, if you can no longer practice. However, since the Great-West/Protective policy is an association policy, this definition could change in the future if Great-West/Protective and the ADA decide to change the coverage.
The Great-West/Protective policy also has coverage for partial disability, if you are still able to work but your ability to work full-time is limited. This is sometimes a good option for dentists with neck, back or hand pain that is not yet constant, and subsides with rest. In this instance, it may be appropriate to reduce the number of days you are working and file a partial disability claim. However, there are certain threshold losses that must be established to qualify for partial disability and, in some instances, you may not be able to collect partial disability without first having a period of total disability (depending on the scope of coverage you purchased). Accordingly, you should not modify your work schedule or file a partial disability claim without first speaking with a disability attorney.
3. How and when must I file a disability claim with Great-West/Protective?
In order to file a Great-West/Protective disability claim, you must submit the proof of loss required under your Great-West/Protective policy. Most Great-West/Protective policies require this proof to be submitted in writing and within a certain time limit—typically within 20 or 30 days from the date of loss, or as soon as reasonably possible, up to within 120 days of the end of the policy elimination period (which can vary policy to policy, depending on the waiting period the dentist selected when applying for the policy).
If you are a dentist with a slowly progressive condition, like chronic neck, shoulder, back or hand pain and/or progressive cervical or lumbar radiculopathy, it can be difficult to know when you cross the threshold of suffering a recognizable loss under your policy. Notice rules also can vary from jurisdiction to jurisdiction, so if you have questions regarding when to file your claim, you should speak with a disability attorney.
The first step is obtaining and submitting Great-West/Protective’s initial proof of loss packet, which will consist of several forms for you to complete and sign, along with a form for your doctor to complete and sign.
Great-West/Protective makes its disability forms available online, or you can call in to a general number to start the claim process. If you call in, our attorneys have observed that Great-West/Protective may subject you to an impromptu interview, so you should be prepared to answer important questions impacting your claim the very first time you are on the line with them.
If you are planning on having an attorney represent you on your claim, it is better to consult with counsel prior to making this initial call, so that you are not subjected to questioning before securing legal representation.
4. When does Great-West/Protective’s disability claim investigation begin?
Great-West/Protective will begin investigating your disability claim the moment you make them aware of your intent to file a claim (which is typically in the initial call to request the proof of loss packet).
Dentists often wonder, “if I call into Great-West/Protective, will the call be recorded?” The short answer is, if you are planning on calling Great-West/Protective to request a claim packet without an attorney, you could be asked questions on a recorded line that could forever affect your ability to collect disability benefits. Disability claims can go on for years and insurers will often compare later responses to prior recorded calls to see if there are any inconsistencies that could undermine your credibility.
Great-West/Protective’s policy provisions, many of which can seem innocuous, actually can be used to limit, deny or terminate a claim. Some questions may include:
- What are your symptoms, and when did they start?
- Describe all treatments/medications you’ve tried?
- How many doctors have you seen? What is their contact information?
- What are your job duties, including your duties as a practice owner, and what percentage of time do you spend on each duty?
- How much time have you taken off work? When do you plan on going back? Can you go back to work part-time or with accommodations?
- What does a typical day look like for you?
- Once you stop practicing, are you going to work somewhere else?
- When did you last work, and why did you decide to file your claim now?
- What is your income? Have you had a loss in income? Are you filing a total or partial disability claim?
The next inevitable question is, can I tell Great-West/Protective not to record my calls? Whether calls can be recorded is something that varies from jurisdiction to jurisdiction. If you call into the number provided and it states that calls are recorded for training or quality-assurance purposes, that is a sign that your call will likely be recorded. In our experience, most insurance companies record calls relating to dentist claims and keep the recordings in your claim file.
It can be helpful to have an attorney act as an intermediary for your claim and have all calls go through your attorney, and have your attorney present on the line for all interviews with the insurer.
5. Do you have any tips for filling out Great-West/Protective disability claim forms?
Insurance forms are complex and contain trick questions, and disability insurance forms are no exception. Dentists often come to us asking “do I need to fill out this part of the form/can I leave this question blank?” “Why is the company asking for this? It doesn’t apply to me.” “Why are they asking for my taxes/asking about my finances?” While insurers are entitled to investigate your disability claim, most initial paperwork is overly broad and in some instances it may be appropriate to skip certain questions.
That being said, as your claim progresses, your analyst will be conferring with a team of attorneys and other consultants to identify any deficiencies in your responses. Fear of this happening can sometimes prompt dentists to over-share and provide too much, irrelevant information. So there is a delicate balance between failing to prove up your case by offering up too little information and potentially overcomplicating your claim by providing too much information.
Below are a few tips to review before completing your Great-West/Protective claim forms:
1. Read your entire policy before answering any questions. If you do not know how your policy works, you will not understand why certain questions are being asked. And if you don’t understand the “why,” it is easy to prejudice your claim by providing too much or too little information.
Many dentists expect that, since they have the ADA policy, they don’t need to devote a lot of time to their claim, someone affiliated with the ADA will be guide them in the process, and they will be told everything they need to know or be aware of. They do not realize, until it’s too late, that the claim investigation is administered by Protective—not the ADA. And, while there are legal requirements that require insurers and third-party administrators to refrain from misleading policyholders, courts also expect you to have read and understood the contract you are filing a claim under.
Accordingly, relying on Protective or anyone associated with your disability insurance company to hold your hand is a bad idea. You need to be proactive about protecting your interests, and be informed going into the disability claim process.
2. Be mindful of each form’s significance in the scope of the entire claims process. Generally speaking, the initial proof of loss packet is the most important set of claim forms because it sets the tone for your entire claim. Claim analysts are trained to review these forms to help determine your occupational duties under your policy, the extent of your restrictions and limitations (including the severity, frequency and duration of your symptoms, and possible job modifications), what additional information is needed, how your claim should be characterized under the policy (e.g. partial v. total disability, injury v. sickness, etc.), and what additional steps should be taken when investigating your claim in light of the policy’s requirements and limitations.
It’s also important to keep in mind that, unlike other insurance claims, disability claims require ongoing, monthly proof of loss to continue to qualify for benefits. Consequently, you will be completing other forms and submitting additional information on an ongoing and frequent basis, particularly in the first several years of the claim.
Each time you submit additional information or forms, claim analysts are trained to identify any inconsistencies with prior information in the claim file. If there are inconsistent answers, this undermines your claim and can cause it to be flagged for heightened review and possible denial or termination.
3. Read each question carefully, and read each form through at least one time before answering any of the questions. Most disability paperwork is divided by topic, and each section often has specific instructions that can be easy to miss.
For example, at the outset of the claim, many forms will ask to you answer certain questions based on the facts immediately prior to your disability, since that is the timeframe that is generally the most critical in a disability claim. Some questions may ask for you to list employment or medical information from prior timeframes, while others may be more focused on your current employment status or current symptoms.
Timelines are particularly critical in disability claims. Analysts determine your “occupation” and categorize claims based upon your pre-and-post-disability work history and activities. Most claims also involve several other key dates that determine whether your claim is subject to preexisting condition limitations, whether you timely filed proof of loss, what your prior income should be for purposes of partial disability calculations, and the list goes on. If you create confusion regarding your claim’s medical or occupational timeline, it can lead to significant delays and, in some instances, denials that can only be sorted out through lawsuits.
4. Review your answers to make sure you have not been too sparse or generic. If you have not been involved in a disability claim before, the scope and nature of some of the questions can seem overly intrusive. Over the years, we’ve become involved in several claims where a dentist reviewed the paperwork, did not understand why certain information was being asked, skipped those questions, and returned partially completed forms. This inevitably leads to frustrating delays, as insurers typically refuse to move disability claims forward unless/until they receive all requested information.
If you do not understand a question or why certain information is being requested, or are concerned that answering a question may expose you to legal liability, you should not answer without consulting with an attorney first. However, if you are refusing or failing to provide relevant information, you are not only giving the insurer an excuse for delays, but potentially making it easier for the insurer to deny your claim.
Insurers often rely on medical and other consultants to determine whether a claim should be paid. If, for example, you do not provide sufficient details and documentation regarding the precise nature of your condition, it makes it much easier for the insurance company’s doctor to conduct a cursory “file review” and determine there is insufficient information to verify disability. Similarly, if you refuse or fail to provide occupational information, it opens the door for your insurer to misconstrue your occupation and/or refuse to pay benefits until you submit the relevant financial information needed to determine your potential eligibility for benefits.
Sometime it is also appropriate to go beyond the bounds of the form if your particular situation is nuanced and the questions asked within the four corners of the claim form do not provide adequate context for your claim. However, you should be cautious about providing too much information, as this can also confuse issues, delay the processing of your claim, and prejudice your ability to collect benefits (see Tip #5, below).
5. Review your answers to make sure you have not been too detailed or specific. Keep in mind that the insurance company designed the form you are completing. It is has likely gone through several revisions (with attorneys and risk management professionals) and has been fine-tuned to elicit responses that can be used to limit or deny payment. So each time you answer a question, you should be considering the specific basis for the question and whether you are oversharing information that can be used against you.
For example, some forms contain open-ended questions designed to prompt you to provide additional details about your personal life that can later be used to make it easier for the insurer to look you up online, find family member’s social media accounts to see what they are posting about you, etc. The company may ask about your daily schedule, and if you give a lot of details, breaking your days down hour-by-hour, you are just providing them with a roadmap to give to their investigators if they decide to conduct in-person surveillance on your claim. Or the form might ask about your “hobbies,” or give you a list of activities (unrelated to your occupation) and ask you to identify what you can and cannot do. These responses are then used to determine if you have any interests or activities that they could argue are inconsistent with your reported limitations.
As another example, the volume of financial information that is relevant in a partial disability claim is typically significantly larger than the financial information that is relevant to a total disability claim. However, oftentimes insurers will request everything as a matter of course, which can lead to unnecessary delays and oversharing of personal financial information that can be used against you.
However, it can be difficult to parse through the relevant and irrelevant without the aid of an experienced disability insurance attorney, and if you repeatedly refuse to provide relevant information, that can be a legitimate basis for a claim denial. So if you are concerned about the scope of questioning, it is advisable to contact a disability attorney before submitting anything (if you do not already have one).
6. Re-read all your answers to ensure they are accurate. Once you sign and submit your responses to the insurance company, your insurer (and courts) will hold you to those responses. Like other insurance forms, disability paperwork includes fine-print stating that you carefully and accurately completed them, whether or not that is actually the case.
For example, Great-West/Protective’s claim paperwork states that, by signing the form, you “hereby certify that [you] have carefully read the foregoing questions and fully understand them, and that each answer is true and complete to the best of [your] knowledge and belief.”
If you purposefully deceive the company, there can also be significant legal consequences, as noted on Great-West/Protective’s initial claim form, which provides notice that “[f]iling a statement of claim containing any false, incomplete, or misleading information with an intent to defraud or deceive any insurance company is considered to be a felony in some states.”
At the very least, if you need to correct a mistake on prior paperwork it undermines your credibility, draws more attention to your claim, and can make it more likely that the insurer will take additional investigative action, such as in-person surveillance. Accordingly, you should always double-check everything submitted in connection with your claim to ensure it is accurate.
These are just a few tips related to completing forms, and each claim is different and involves different facts and different considerations. Remember, insurers often use ambiguity to wrongfully deny claims; however, at the same time, providing too much information, inaccurate information, and/or answers that are not well thought-out can also prejudice your ability to collect without a lawsuit. Even if you are right, and ultimately win, litigation is costly and protracted litigation can leave you financially vulnerable.
Consequently, it is much better to carefully complete the claim forms correctly from the beginning and submit your claim properly from the outset. If you do not understand your policy or have experience with how Protective handles claims, it can be difficult to sift through the forms and identify what you should/should not say. Accordingly, it is advisable to at least consult with an experienced disability attorney before filing your claim, so that you have an understanding of what to expect when you file and can identify any issues you need to specifically address relating to your claim.
6. As a dentist, what should I expect after filing a Great-West/Protective disability claim?
After the initial proof of loss packet is submitted, Great-West/Protective will assign your claim to a benefit specialist, and he or she will send you a list of the additional information needed to evaluate your particular claim.
Ongoing Proof of Loss. As the claim progresses, Great-West/Protective will require ongoing proof of loss and additional paperwork to be completed by you and your doctor(s). The paperwork will include questions relevant to various policy provisions that may limit your coverage, so it is advisable to be represented by an attorney.
Records Requests. After you submit the initial claim documents, Great-West/Protective will likely send a follow-up letter requesting additional records and documents. For dentists, this usually includes financial documents (such as tax returns), CDT codes, profit and loss statements, employment agreements, and practice sale documents, among other things. Whether these requests are appropriate depends on the terms of your policy and nature of your claim, and should be reviewed by an attorney.
Interviews. In addition to periodic phone interviews, Great-West/Protective may hire a field examiner to interview you in-person. This interview typically takes place at your attorney’s office, or at your home if you are not represented by an attorney, and interviewers/investigators may arrive unannounced if you are not represented. Great-West/Protective may also seek to interview your former co-workers and/or employers about your prior job duties, and may seek to interview your friends or family members about the impact your condition has had on your day-to-day life. Whether these types of interviews are appropriate depends on various factors, including the particular issues at play in your claim.
Disability Examinations. Almost every disability policy contains a provision that allows the company to have you examined as part of the claims investigation. Older policies typically only expressly allow for “physical” examinations, while newer policies are typically much more detailed and list several different types of exams, including mental exams, vocational evaluations, rehabilitation evaluations, functional capacity evaluations, and/or neuropsychological testing, in addition to physical exams. Whether an exam is appropriate depends on the particular facts of your case, and the underlying policy language.
Disability-Related Surveillance. Great-West/Protective is a company that conducts surveillance, including online and in-person surveillance. Great-West/Protective generally begins by reviewing your online presence/social media and then moves on to in-person surveillance if they feel that is warranted. If you have a partial disability claim with Great-West/Protective or keep a passive interest in your practice, Great-West/Protective will periodically review your practice’s website and social media to assess whether any posts suggest that your activity levels at the practice vary from what has been reported to Great-West/Protective.
Peer to Peer Calls. When you file your disability claim, Great-West/Protective will typically assign your claim to an in-house doctor and pay that doctor to review your medical records and look for any gaps or inconsistencies. Often, Great-West/Protective will then direct their doctor to call your treating doctors in what is called a “peer to peer” call. Great-West/Protective may tell you this is going to happen, but in most cases this takes place behind the scenes without your knowledge. In these calls, Great-West/Protective’s doctors ask questions that are crafted to elicit responses that the company can use to deny or terminate your claim. The best way to prevent this from happening is to have all correspondence with your medical providers be in writing and go through a disability attorney.
This process can feel very invasive and, if you have never experienced it before, it can be hard to tell whether your insurer is taking things too far. If you are unsure whether Great-West/Protective is acting appropriately, an experienced disability insurance attorney can help you to assess/limit the scope of any overly broad or improper investigation,
7. If I have doctor support/a letter from my doctor saying I’m disabled is there any way Great-West/Protective can still deny my claim?
Many dentists assume that if their doctor signs off on their disability, they will have no trouble collecting. In their mind, the only question that needs to be resolved is “how do I get my doctor to sign off that I am disabled?”
While your treating physician’s support can often be critical to getting your claim approved, insurers routinely deny claims that have support from treating physicians. There are a number of reasons for this, such as sparse medical records, gaps in treatment timelines, failure to get support from the proper medical specialist, and the list goes on. Insurance companies also have their own doctors that may disagree with your doctor’s opinions regarding your restrictions and limitations. Insurer’s doctors also frequently conclude that treatment plans are not aggressive enough, and x, y, or z treatment could return you to work. Thus, support from your physician alone, is not enough to secure disability benefits.
Additionally, finding a helpful physician is not always an easy task. A hurried, uninterested physician may not have time to devote to your claim, and Great-West/Protective is a company that typically requires a significant amount of medical documentation before approving a disability claim. You will need to find a treating doctor who is willing to take the time to understand how your policy works, complete claim paperwork and potentially answer follow-up questions from Great-West/Protective’s in-house doctors.
When the time comes to speak to your treating physician about your claim, it is also important that your doctor understands the definition of “disability” under your insurance policy—particularly if you have a “true own occupation” claim where disability is defined as the inability to practice dentistry (even if you can work in another capacity). Otherwise, if you start a new job, your doctor may assume you are no longer pursuing the disability claim and answer that you can resume working, even if your new job is unrelated to clinical dentistry.
In our experience, Great-West/Protective’s consulting physicians are reluctant to provide your treating doctor with information regarding your job duties and important policy provisions before commencing an interview. If you are represented by at attorney, measures may be taken to ensure that interviews are scheduled through counsel and are even-handed.
8. I am a dentist with a Great-West/Protective disability policy; do I need to hire a disability attorney to file my claim?
While there are certainly claims that may not require attorney involvement—for example, a disability claim due to the loss of a limb or something very serious, such as paralysis—in our experience dentist claims are not that straightforward.
Many of our clients have slowly progressive conditions, conditions that may/may not respond to future treatment, or conditions that are irregularly and unpredictably debilitating, such as musculoskeletal conditions due to degenerative disc disease, Parkinson’s Disease, MS, Cystic Fibrosis, POTS, or seizures/migraines caused by periodic intracranial hemorrhages.
Other clients have conditions like a tremor, that may not prevent them from working in other jobs, but have a significant impact on their ability to work as a dentist. Others have mental health conditions (anxiety disorder, panic attacks, PTSD) that cannot be verified by a single, definitive objective test.
These sorts of nuanced claims receive heightened scrutiny, including early and proactive involvement by a senior claims analyst, and direct and continued involvement of vocational/medical professionals with a return to work focus (often for the duration of the claim).
Obviously, if your claim is denied or you have a dispute over policy interpretation, you may need an attorney to become involved to resolve the matter. That being said, lawsuits with insurance companies are often costly, stressful, and, in some instances, can drag out over several years, all to the insurance company’s advantage Even if you prevail it can be an exhausting process, and companies typically appeal, which can take at least another year or more, all the while you are not getting paid benefits
In our view, it is more prudent to approach your claim carefully from the outset and have your attorney address any concerns that the insurer may have over the course of the investigation itself, so that you are not placed in a position where benefits have been cut off, you are not working and your only option is a lawsuit.
In our experience, the most common areas where complexities can arise in dentist claims include:
- The timing of the claim (particularly in situations where a disabling condition is slowly progressive);
- Claims made by dentists who own their practice and need to decide whether to sell, bring on new associates, or keep working in a limited capacity;
- Claims where the underlying condition is difficult to diagnose or is diagnosed by exclusion;9Claims involving multiple co-morbid conditions;
- Claims involving recommendations for or against surgery; and
- Claims involving mental health conditions.
9. When should I contact an attorney about filing my Great-West/Protective disability claim?
Dentists who are considering filing a claim for disability insurance benefits should meet with a disability attorney well-before submitting a claim.
Each disability policy has different, complex language that insurance companies may manipulate to circumscribe and restrict coverage. Before filing, dentists should make a coordinated effort, with an attorney’s assistance, to determine whether their particular claim is covered, and if so, how that claim is best presented to ensure payment.
Great-West/Protective Claim Tips and Answers to Other Common Great-West/Protective Questions
10. I heard the American Dental Association (ADA) disability policy is different from private disability policies. How is it different?
The ADA Disability Income Protection Plan is an association disability policy. Association policies differ from individual disability insurance policies in a few important ways. First, the insurance contract is between the ADA and Protective (rather than between you and Protective) and the ADA is the policyholder. This means that the ADA and Protective can change the underlying policy (and your coverage) at any time before you file a claim, without needing your approval.
For example, Protective and the ADA can change critical terms of the policy, such as changing your eligibility for benefits, changing the age to which benefits are paid, or increasing the medical care requirement without your consent. Although you would receive notice of any changes after the fact, you would not be able to object to or prevent the changes.
We created the list below by comparing a version of an old Great-West ADA policy from the 1980s to a version of the ADA policy from the 2000s, to illustrate how the policy changes over time. The list includes some (but not all) of the parts of the policy that have changed over the years.
- Totally Disabled
- Regular Care of Physician
- Objective Medical Evidence
- Actively Working Full-Time
- Attained Age
- Insured Amount
- Net Monthly Income
- Extension of Benefits
- Premiums – Payment
- Premiums – Default
- Minimum Insured Amount
- Max Insured Amount
- Suspension of Coverage
- Residual Income Benefit
- Future Increase Option
- Relation of Earnings to Insurance
- Monthly Income Benefit Limitations
- Time and Payment of Claims
- Appeals and Legal Actions
- Furnishing of Information
- Governing Law
- Conformity with Statutes
Some of the above changes added addition requirements for collecting benefits. For example, older versions of the policy did not have the “actively at work” requirement (discussed in more detail below), and prior versions of the policy’s care requirement did not require you to also prove you are receiving “appropriate maintenance care” for your disabling condition. Similarly, earlier versions of the policy did not require “objective medical evidence” or list that as a defined term in the policy. Other changes have been beneficial for dentists. For example, several years ago, the ADA increased the length of the benefit period from age 65 to age 67 for disability claims filed after that change was made.
In sum, there is some degree of uncertainty and lack of control inherent to association policies. While the policy should, generally speaking, track the interests of the ADA’s members, those interests may not always align with the best disability coverage. For example, if the ADA were to determine its membership wanted lower premiums, certain features could be eliminated from the policy in the name of cutting costs for ADA members.
If you have an ADA policy, it is important to keep all of the notices you receive and have an attorney review your policy prior to filing your claim, so that you have an up-to-date and accurate picture of your coverage if/when it comes time for you to file a disability claim.
11. What will Protective’s administration of my Great-West/Protective disability claim mean?
Protective’s purchase of Great-West/Protective marks Protective’s first entry into the professional disability insurance market. Although it does not have a long track record or experience in administering disability insurance claims, it has been the subject of a multi-state targeted market conduct examination regarding its practices in handling life insurance claims.
This market conduct examination, led by the Pennsylvania Insurance Department and joined by insurance regulators from multiple states, found that Protective had violated numerous regulations when handling life insurance claims in an effort to save money, including:
- Misrepresenting policy provisions to insureds;
- Failing to act promptly in response to communications from insureds; and
- Failing to adopt and implement reasonable standards for the investigation of claims.
As a result of the market conduct examination, Protective was forced to enter into a regulatory settlement agreement. Protective paid a fine and agreed to revise its practices, but it is unclear what lasting effect this regulatory settlement agreement will have on Protective’s claim practices.
At a minimum, it is important to recognize that Protective is approaching your claim from the perspective of claim management. As a member of the ADA, you may expect that the ADA has your best interests in mind and your claim will receive special treatment. But when you file the claim, you will be dealing with Protective, not the ADA.
12. I am a dentist and an ADA member; how difficult will it be to collect my ADA Great-West/Protective disability benefits?
The Great-West/Protective policy requires that you provide “Objective Medical Evidence” to collect disability benefits, something not required under other disability insurance policies. This is significant because not all conditions can be definitively diagnosed through diagnostic testing. Nerve conduction studies and electromyelography can result in false negatives, MRI studies may fail to show brain lesions indicative of multiple sclerosis, and imaging results of spinal degeneration do not necessarily correlate with the symptoms a patient experiences.
We have found that many analysts are resistant to recognize legitimate claims without definitive diagnostic testing which, in some cases, may simply not be possible. Accordingly, if you suffer from a condition that is difficult to diagnose through medical testing, or for which objective testing is inconclusive, it is a good idea to consult with a disability attorney regarding your claim and what you can do to prove up your particular disability.
13. Can Great-West/Protective force me to have surgery?
Although the Great-West/Protective insurance policy is an “own-occupation” policy, the policy has a strict medical care provision, which requires care to be directed towards the “cure, alleviation, or minimization of the condition causing disability” and a “return to the substantial and material duties of your own profession or occupation” or “maximum medical improvement with appropriate maintenance care.”
In other words, if Protective believes that there is a treatment or surgery that could possibly allow you to get better and return to dentistry, Protective may refuse to pay further benefits if you do not undergo the treatment or have the surgery.
We often see this come up is in cases involving dentists with degenerative disc disease in the cervical or lumbar spine. Although surgery, for example a disc fusion surgery, can be a potential treatment, there are a number of risks associated with spine surgery. In particular, dentists who undergo fusion surgery are susceptible to adjacent level disease—degeneration in the discs surrounding the fusion site—as a result of the increased strain put on the fused discs.
If you have a condition that could possibly be treated with surgery, but you are reluctant to pursue surgery because of potential risks or complications, it is important that you and your disability attorney fully explore the dangers of the procedure and be prepared to explain those dangers to Protective.
14. Will working part-time as a dentist affect my disability coverage under the Great-West ADA policy?
As noted above, the ADA Great-West/Protective policy is intended for dentists who are practicing and part of the ADA. As a result, the ADA policy has specific, additional requirements relating to eligibility that other disability policies do not have.
Specifically, in order for you to be eligible to file a claim under the policy, you must be “Actively Working Full-Time,” which is currently defined under the policy as “[w]orking at least 20 hours per week” performing “all the substantial and material duties of clinical dentistry.” (However, as noted above, the total hours can be changed at any time, as the ADA policy is a group policy, so you need to keep apprised of any updates related to this “active work” requirement.)
In our experience, it is not uncommon for dentists who suffer from chronic pain and slowly degenerative conditions to reduce the length of their work days/work week over time as their conditions progress. If you have the ADA policy and reduce your hours too much, you can prejudice your chances of collecting benefits. Similarly, if you are working more than 20 hours per week total, but split that time between clinical, chairside setting and some other role, such as an administrative or management role, you could also jeopardize your coverage.
The ADA policy does have some exceptions—for example, scheduled absences lasting less than 60 days—and ways to regain eligibility if you fail to meet the “Actively Working Full Time” requirement. However, many require that specific, affirmative steps be taken on your part to regain coverage. If you are not aware of these steps, or fail to provide notice in the proper format, you can potentially permanently lose eligibility under the Great-West/Protective policy and not have the policy available to you when you need it the most.
Additionally, while the ADA policy can provide disability benefits if you are working-part time, there are specific legal requirements and threshold losses that must be met and established. Depending on the riders you selected when applying for the ADA policy, you may not be able to file for partial benefits unless/until you have first satisfied the policy’s elimination period with a period of total disability.
Consequently, you should speak with a disability attorney as soon as possible if you are a dentist with the Great-West/Protective ADA policy and are considering reducing your work schedule due to disability.
The information provided above is offered purely for informational purposes. It is not intended to create or promote an attorney-client relationship, and does not constitute and should not be relied upon as legal advice.
Every claim is unique and the discussion above is only a limited summary of information that may be relevant to your claim. If you are a dentist and concerned that Great-West/Protective is not handling your claim fairly, an experienced disability insurance attorney can help you assess the situation and determine what options are available to you.
Notable Great-West/Protective Disability Insurance Cases
Phan v. Great-West Life and Annuity Ins. Co., Case No. CV 13–1318 GAF (ANx) (C.D.Cal. 2013).
Doe v. Great-West Life and Annuity Ins. Co., 208 F.3d 213 (6th Cir. 2000).
Great-West/Protective Disability Insurance Blog Posts