How To Avoid Common Obstacles When
Filing A Disability Insurance Claim

You have worked hard your whole career to develop your dental practice, but now you fear that you can no longer treat patients because of a physical or mental condition.  You’re not alone—statistics show that from the time a person turns 35 to the time they reach retirement age, they have a 50% chance of experiencing a disabling condition that lasts at least three months.  In the whole population, one out of every seven workers will eventually become disabled for more than five years before they reach age 65.  In fact, your odds that you will become disabled and unable to work are far greater than the odds that you will die before you retire. Thankfully, you recognized this possibility, and purchased a private disability insurance policy to offset the risk that a health condition may, one day, prevent you from working.

Unfortunately, insurance companies who heavily marketed and sold these policies throughout the ‘80s and ‘90s are now doing everything in their power to maintain profits and avoid making payments on legitimate disability claims.  What can a dentist do to avoid the pitfalls of the disability insurance claim process and prevent their claim from being denied or terminated?

Insurance companies have designed a sophisticated system to terminate or deny claims and at the same time minimize their exposure to lawsuits for bad-faith insurance practices.  Among the many hurdles that you will have to overcome during your claim are:

    • Interpreting and following the complex language that insurance companies use when drafting insurance policies, in order to ensure that you do not take any actions that will harm your claim;
    • Preventing insurance companies from wearing you out through their efforts to cause undue delay by insisting that you follow an overly burdensome claim process;
    • Working with your treating physician to ensure that your disability is properly and effectively documented in your medical records;
    • Recognizing and avoiding insurance companies’ attempts to use secret surveillance to justify terminating or denying your claim;
    • Preventing independent medical evaluations from becoming harmful, or painful, or otherwise violating your rights;
    • Avoiding insurance companies’ efforts to deny your claim because your symptoms are subjective or not objectively verifiable; and
    • Recognizing and overcoming the many other techniques that insurance companies use to avoid paying legitimate disability insurance claims.

Overly Complex and Confusing Disability Insurance Policy Language

Disability insurance policies are drafted by insurance companies and their attorneys with an eye toward the companies’ interests—not yours. Insurance companies often capitalize on the ambiguities and confusing terms in their policies at the expense of legitimate claimants.  Often insurance companies will attempt to construe ambiguous terms or phrases in a way that will support denying a claim, when in fact, if the claim went to litigation, the court would construe those same ambiguous terms against the drafter of the contract (the insurer) and in favor of the other party (the claimant). There is no “standard” insurance policy contract, and it is important to understand the actual meaning of the terms, and when the policy provisions may not say what the insurance company asserts that they say.  In order to overcome efforts by insurance companies to construe jargon and legalese in a way that allows them to deny or terminate legitimate claims, it is absolutely crucial that a claimant study the policy language and seek advice from a lawyer who is experienced in disability insurance law.  Thoroughly understanding your insurance policy contract may be the most important step to successfully obtaining disability insurance benefits.

Undue Delay in the Claim “Evaluation” Process

Insurance companies have created a system to avoid paying benefits whereby they make the claim “evaluation” process as drawn-out as possible in the hope that many claimants will simply give up out of frustration.  Insurance companies depend on this significant degree of attrition by legitimate claimants to maintain profits.  Sadly, many claimants do not recognize, or have no power to enforce, that insurance companies’ legal obligation to make prompt decisions.

Treating Physicians

Your medical records are perhaps the most important tool for successfully filing a disability insurance claim.  Unfortunately, many physicians are extremely busy and over-worked, and without proper encouragement are not willing to take the time and effort to properly document your condition.  It is not uncommon for busy doctors to simply copy boiler-plate language that they use for every patient into reports of your condition.  For example, a physician might include language like “patient is in no apparent distress” when describing your appearance, when in fact, the purpose of your visit was to receive treatment for your chronic back pain—something that is likely very distressing, and is preventing you from working.  The insurance company might latch onto this sort of language to justify terminating or denying your claim, ignoring the entirety of the doctor’s report.  Fully discussing your condition with a compassionate treating physician who will take an interest in your disability claim is crucial to obtaining medical records that document your condition.

Secret Surveillance

One of the tactics that insurers frequently employ is hiring secret surveillance photographers to videotape you in your day-to-day activities.  If they are able to capture footage of you performing some activity, however brief, that you reported you could not perform due to your disability, they will use this evidence as a basis to deny or terminate your claim.  In addition, they may attempt to contact your treating physician, and even send copies of the footage to your doctor in an attempt to cast you as a liar and sour their opinion of you.  At that point, your doctor may be disinclined to assist you with your claim in the future, and may even be willing to make statements helpful to the insurance company.  It is important to be on-guard and recognize that insurance companies will readily use out-of-context surveillance footage that they can misconstrue to avoid paying your claim.

“Independent” Medical Examinations

As part of an insurance company’s “evaluation” of claims, they will often ask claimants to participate in an “independent” medical evaluation (“IME”). These IMEs are performed by physicians who are chosen and paid by the insurance company, thereby creating an obvious bias whereby the doctor has an incentive to downplay or even mis-diagnose your condition in order to help the insurance company.  In addition, IMEs can be incredibly intrusive, and may even involve tests or procedures that are intrusive, painful or even dangerous.  The primary goal of these exams is often to create further evidence to justify terminating or denying your claim – not to provide a fair diagnosis of your condition.  All too often, they are simply one of the tools insurance companies use to avoid paying your benefits.  Therefore, it is important to be fully aware of your rights before attending an IME.

Non-objective Evidence

The most common conditions for which insurance companies will deny paying benefits are those where there is no objectively verifiable evidence of the condition.  For example, often for chronic back or neck pain, arthritis, or many mental conditions it is impossible to measure the severity of the condition other than through subjective reports from the patient.  Objective evidence may be too difficult or impossible to obtain.  Insurance companies capitalize on this fact, using lack of measurable evidence as a basis for avoiding payment.  Very rarely, however, do the terms of the insurance policy require the insured to provide objective evidence of their disability.  To the extent that policies contain such provisions, they are often written in an ambiguous manner that courts would construe in favor of the claimant.  Therefore, it is absolutely crucial that a dentist with a condition that does not have objectively verifiable symptoms to thoroughly understand the provisions of their insurance policy.

Overcoming These Obstacles

The disability claim process has been designed by insurance companies to be overwhelming and exhausting.  Insurers hope that by making the process difficult, many claimants will simply give up.  Insurance companies know that most of those who don’t give up, will unknowingly succumb to the many tricks and traps that insurers have created to justify denying or terminating a claim.  Insurers’ tactics are not insurmountable; however, the fight can be extremely difficult for a dentist to take on alone, especially when the opponent is a billion-dollar industry devoted to reducing costs and denying claims.

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