MassMutual Disability Claim Tips for Dentists

2. I thought I had a MassMutual “own-occupation” disability policy. Why are there so many riders? How do I know if my “own-occupation” rider covers all of my benefits?

While MassMutual does offer own-occupation coverage, determining whether you have it, and whether it applies to all of your benefits, can be a bit complicated, for several reasons.

First, some companies have separate policy templates for each type of own-occupation coverage they offer. In contrast, MassMutual’s base policy typically defines total disability as the inability to work in your occupation, but adds a default “no work” provision that only allows you to collect total disability benefits if you are not working.

In order to remove this limitation, you typically have to purchase a separate own-occupation rider that amends, or modifies, the base policy definition of total disability to remove the “no work” requirement. On top of this, MassMutual also has partial disability riders that add coverage for partial disability and similarly amend/modify other definitions in the base policy.

While these riders were likely intended to make things more convenient for MassMutual, they make interpreting the policy contract more complicated because the interplay of all riders must be taken into account. So, if you are a dentist trying to decipher how your MassMutual policy works, the first step is to review each rider carefully to see what provisions in the base policy have been changed by the riders and which still apply.

This process becomes even more complicated if you have exercised options to increase your total benefit amount or add other features to your policy. While some companies issue separate policies for each change in coverage, MassMutual typically sends you an updated policy schedule showing the new benefit amount, instead of a new policy describing the additional coverage in detail.

In a sense, this is convenient because you can just replace the old schedule with the new one, without having to keep track of multiple policies. However, this can also make it difficult to determine what policy provisions apply to each increase or change in coverage.

For example, if you decide you want to increase your total benefit amount, but don’t want to pay additional premiums to similarly increase the coverage of your “own occupation” rider, that portion of your monthly benefit can remain subject to the base policy’s “no work” provision. Similarly, MassMutual may not be willing to extend the “own occupation” rider to certain features, such as RetireGuard benefits, or may not be willing to offer full “own occupation” coverage for the requested increase.

As you might imagine, if you exercise these types of increases multiple times over the lifetime of the policy, the policy schedule can become quite convoluted. It’s not uncommon for us to have to explain to dentists that only part of their MassMutual benefits have full own-occupation coverage, and the other part is subject to a “no work” provision.

In sum, if you are confused about how your MassMutual policy works, that is entirely understandable given how they are set up. If you have questions about the scope of your coverage, an experienced disability insurance attorney can review your policy and provide you with a breakdown of your coverage under each rider and each increase/change to the policy.

3. How do I file a disability claim with MassMutual?

In order to file a MassMutual disability claim, you must submit the proof of loss required under your MassMutual policy. Most MassMutual policies require this proof to be submitted in writing and within a certain time frame—typically within 20 or 30 days from the date of loss.

The first step is obtaining and submitting MassMutual’s initial proof of loss packet, which will consist of several forms for you to complete and sign, including an investigative authorization, along with a form with questions for your doctor to complete and sign.

MassMutual requires you to call in to provide initial notice of claim and request a disability claim packet. When you call in, our attorneys have observed that MassMutual 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 disability 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. I am a dentist. Why does my MassMutual disability policy’s definition of “occupation” refer to “businesses” instead of “dentistry”?

Many dentists think their disability policy is a dentist-specific policy that protects them if they are not able to practice dentistry. While this may be the case, how “occupation” is defined under most disability policies is not that clear-cut. It also typically has nothing to do with what you listed as your “occupation” when you applied for the disability policy.

Why? Because most disability policies, including MassMutual disability policies, define your occupation based upon what you were doing immediately prior to your date of disability. The reason is fairly obvious—insurers don’t want to insure you as a dentist if you decide to change your occupation and do something else other than dentistry.

That being said, most post-2000 disability policies have a very expansive definition of “occupation” that is intended to encompass all sources of active income and require you to show you cannot perform your “occupation or occupations” in order to collect total disability benefits. Under some MassMutual policies, MassMutual takes it a step further and refers to “professions” and “businesses,” making it clear that the provision is intended to encompass all sources of active income—dentistry or otherwise.

This provision can be particularly problematic for dentists who seek out other, non-clinical sources of income and/or take on an active administrative role at their practice that is more hands-off on the clinical side. These types of changes should not be pursued without first consulting your disability policy (and, ideally speaking with a disability attorney) as they can modify your occupation and make it much more difficult to collect total disability benefits.

5. Do you have any tips for dentists filling out MassMutual 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.” Or “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, accountants, investigators, 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 claim by offering up too little information and potentially overcomplicating/prejudicing your claim by providing too much information.

Below are a few tips to review before completing your MassMutual 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.

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 MassMutual or anyone associated with your disability insurance company to hold your hand is a bad idea. You need to be informed and proactive about protecting your interests from the start.

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 credibility and can cause your claim 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.

Many questions in this vein are largely irrelevant fishing expeditions, if you are filing a total disability claim under an “own occupation” policy (as opposed to an “any occupation” policy). 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, the fine print in MassMutual’s claim paperwork states that, by signing the form, you “certify that [you] have carefully read the foregoing questions and that each answer is true and complete to the best of my knowledge and belief.” If you purposefully deceive the company, there can also be significant legal consequences. For example, MassMutual’s New York specific fraud notice in the fine print of its forms states “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.”

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.

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 MassMutual handles claims, it can be difficult to sift through the forms and identify what you should/should not say. 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. Does MassMutual try to use surveillance to deny dentist disability claims?

Yes. Like other disability insurers, MassMutual will conduct online surveillance, and potentially hire investigators to conduct in-person surveillance.

Dentist disability claims are often targeted for surveillance because dentists often have high-paying policies and disabling conditions that can cause significant patient safety risks when practicing, but may not be as obvious in day-to-day life. For example, you might have an essential tremor that makes it impossible to operate on dental patients safely, but does not significantly interfere with other areas of your life. Or you might have lumbar DDD that makes it incredibly difficult and painful to sit and the hold static positions required by dentistry, but feels better if you are moving about and generally more active.

While surveillance is not per-se illegal, some investigators hired by MassMutual have, historically, crossed-lines and been overly-aggressive with some of our clients and other dentists we have spoken with. In some instances, this involved trespassing on private property; in others, it involved tailing too closely, or following family members or friends instead of the actual claimant.

If you have concerns about the scope of surveillance, or are being harassed by insurance company surveillance, a disability insurance attorney can help you determine if the surveillance is appropriate, and if your benefits are in jeopardy.

7. Do I need to hire a MassMutual 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 typically are not that straightforward.

Many of our clients have more nuanced conditions, such as slowly progressive musculoskeletal conditions due to degenerative disc disease. Others 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.

Notably, MassMutual policies can have provisions limiting recovery for mental health conditions to 24 months. Some insurers add these exclusions as riders to their base policies; however, some MassMutual policies include this limitation in the middle of the base policy, where it is easy to miss.

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.

Filing a disability claim also becomes more complicated if you have multiple disability policies with different insurers that may have conflicting provisions or different definitions of disability. If you have high benefits amounts and/or you are a relatively young claimant with a potentially permanent condition, your claim is likely to receive more scrutiny.

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 or the where dentist works too long in spite of his/her condition);
  - 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 involving multiple policies with different insurers;
  - Claims initially handled by the dentist individually, without legal representation;
  - Claims where the dentist has already submitted to an interview under oath or an insurance company medical exam;
  - Claims involving inadequate medical work-up and/or limited treatment history;
  - Claims involving high benefit amounts, young claimants and potentially permanent conditions;
  - Claims involving conflicting recommendations for or against worksite modifications, certain treatments, procedures and/or surgery;
  - Claims where the underlying condition is difficult to diagnose or is diagnosed by exclusion;
  - Claims involving musculoskeletal conditions; and
  - Claims involving mental health conditions.

8. When should I contact an attorney about my 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. Disability policies have evolved over time, and professional disability policies now have several provisions that must be taken into account before filing a claim, such as minimal thresholds for medical care and who qualifies as a treating physician under the policy (e.g. cannot be a family member, must be a doctorate-level practitioner for mental health claims, etc.).

Other examples include policy provisions relating to work status, eligibility to file (sometimes tied to how many hours you are working); ability to work (whether or not you are actually working); lack of worksite modifications that would allow you to work/requirements to pursue available accommodations; loss of income thresholds; submission of “objective” evidence; and deadlines that must be met to timely file a claim or lawsuit. Some policies also require statements or interviews under oath that can be taken as soon as you give notice of your intent to file a claim.

Dentists, in particular, need to be mindful about making changes without consulting an attorney or their policy first. In our experience, many dentists respond to a potentially disabling condition in ways that can limit or reduce their capacity to claim disability benefits, and this is not lost on insurers.

For example, reducing clinical hours and seeking out other sources of employment can modify your occupation under your disability policy. Reducing hours as a form of self-treatment, without having a medical workup, can make it difficult to prove up your disability (or claim disability at all, if you cannot satisfy the policy’s care requirement). Bringing on associates and taking on more administrative duties for extended periods of time can also modify your occupation. And selling your practice but staying on as a “consultant” for the buyer can make it more difficult to claim total disability and potentially only leave you with the ability to claim partial disability benefits.

Accordingly, before filing, dentists should make a coordinated effort, with an experienced disability attorney’s assistance, to determine whether their particular claim is covered, and if so, how that claim is best presented to ensure payment.

9. MassMutual already approved my disability claim. Why are they asking for another interview?

Under virtually all disability policies, if your claim is approved, the disability company has the right to request ongoing proof of loss, typically on a monthly basis. Depending on your condition, you may be placed on a reduced reporting schedule (e.g. every 4 months, or every 6 months), but the company can revisit your claim at any time.

If MassMutual is asking for an interview, it could be routine, but most often it is because something drew attention to your claim. Common examples include a new medical diagnosis or a new treatment option becoming available that MassMutual’s doctors believe will cure or alleviate your symptoms.

Another common example is you starting a new job. Even if you have an own occupation policy, new jobs can provide an opportunity for the company to reduce your benefit. For example, if there is overlap with your prior job, MassMutual may argue you are no longer totally disabled and are only entitled to partial disability benefits. If the duties of the new job are inconsistent with your reported medical limitations, MassMutual could argue that your new job shows you have recovered and are no longer disabled at all. Additionally, as noted above, MassMutual’s base policies typically contain “no work” provisions that allow MassMutual to cut-off total disability benefit if you return to work, in any capacity.

Accordingly, if you are on claim and anticipating a significant change to your work or medical status, it is a good idea to at least speak with a disability law firm. A disability attorney can help explain how the change could impact your claim and prepare you for any interviews or heighted scrutiny that may come as a result.

10. Why is MassMutual contacting my doctor? Should I be concerned?

In our experience, MassMutual does not shy away from hiring reviewing doctors who are biased in favor of insurers. This is common among disability insurers, and MassMutual is no exception.

Like other insurers, MassMutual’s doctors will sometimes attempt to engage in peer-to-peer calls with your doctors. This can be a problem for your claim, because treating doctors often don’t have time to field these calls, don’t always understand how “own occupation” policies work, and may not explain important nuances of your condition because they need to get off the phone quickly to see other patients. In some instances, the treating doctor just ignores the calls because he or she is too busy. If this occurs, the company will typically deny the claim, citing a lack of medical support.

MassMutual’s in-house doctors are generally fairly experienced in this realm and adept at pushing and prodding your treating physician for information that can be taken out of context to challenge your claim. For example, if you have surgery, they might ask your surgeon if the surgery was “successful” and if you can “return to work” when you heal, without mentioning that your policy is “own occupation” or that a return to work means returning to operating on dental patients. Your doctor might reply, “I don’t see why not,” not thinking much of it. Then MassMutual documents in it’s file that your doctor gave them a firm return-to-work date and there is no reason why you can’t return to dentistry.

Because of this, it is best to have a disability lawyer involved from the start if you have a more complicated or nuanced medical condition (e.g. degenerative disc disease, Parkinson’s Disease, MS, Cystic Fibrosis, POTS, or seizures/migraines caused by periodic intracranial hemorrhages, etc.). A disability attorney can monitor MassMutual’s requests and act as an intermediary to prevent peer-to-peer calls and ensure that your medical condition is fully and accurately documented in your disability claim file.

11. What is a rehabilitation benefit/rehabilitation program, and why is MassMutual pushing me to agree to a rehabilitation plan?

Some MassMutual policies include a benefit that gives MassMutual the option to pay for certain rehabilitation services to help get you back to work, such as vocational schools, business schools, or certain types of therapy.

If you have a permanent condition, or one that is likely permanent, then MassMutual has an incentive to get you back to work so that they do not have to pay total disability benefits for the remainder of the policy.

In some instances this could be beneficial and help to ease the financial burden of you getting back to work; however, it’s important to be mindful that agreeing to such a program involves giving MassMutual more oversight over your day to day activities and creates additional reporting requirements for you. In some instances, the plan may also involve being seen by a doctor of MassMutual’s choosing to check-in on your progress and limitations.

12. What is a Catastrophic Disability Benefit Rider? How does my MassMutual catastrophic disability benefit rider work?

Some MassMutual disability insurance policies may include a Catastrophic Disability Benefit Rider. These riders provide for a benefit to be paid if the insured becomes catastrophically disabled. The purpose of this is to cover situations where an individual may not be able to live independently.

MassMutual defines catastrophically disabled as one of two ways. The first is to meet the definition of presumptive disability, which includes:

- Loss of speech
- Loss of hearing in both ears
- Loss of sight in both eyes
- Loss of use of both hands, or both feet, or one hand and one foot.

In the alternative, catastrophic disability can be defined as the inability to perform two of six Activities of Daily Living (ADLs) without assistance (activities of daily living include bathing, continence, dressing, eating, toileting or transferring) or having a severe cognitive impairment. MassMutual defines severe cognitive impairment as resulting in the need for substantial supervision, and that cognitive impairment must be “evidenced by global impairment of ADLs as demonstrated by standardized neurocognitive testing.” Examples include:

- Moderate to severe Alzheimer’s disease
- Severe traumatic brain injury
- Parkinson’s dementia
- Huntington’s dementia
- Vascular dementia
- Severe cerebral vascular accident

It is important to reiterate that it is not enough to just have a diagnosis, no matter how serious. The condition must also have reached the level where ADLs are severely impacted. In the end, it may come down to a battle between your experts and MassMutual’s experts regarding the severity of a given condition if you are trying to establish severe cognitive impairment under your policy.