Ohio National Disability Claim Tips for Physicians
Our law firm has extensive experience handling disability claims for physicians. Our attorneys understand how Ohio National operates and what it takes to file a successful Ohio National disability claim, and are happy to set up a free consultation to discuss your particular Ohio National disability claim.
Below are some answers to the most common questions our attorneys receive from physicians about the disability claim process, generally, and their Ohio National disability benefits, specifically.
Table of Contents
5. Ohio National is asking for my medical practice’s financial records. Do I have to provide them?
6. What types of physician disability claims are most often challenged/denied by Ohio National?
7. Will Ohio National recognize my occupation/medical specialty?
14. When should I contact an attorney about my Ohio National physician disability claim?
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1. My physician disability policy is with Ohio National Financial Services. Why isn’t Ohio National handling my disability claim?
Ohio National does not personally administer many of its claims under its policies, instead opting to hire third-party administrators to investigate physician disability claims. For example, we have seen third-party administrator DMS/Davies being assigned to Ohio National physician disability claims.
A third-party administrator is a company that sets up a claim administration framework and then oversees claims for other companies (often times many different disability insurers). This is most common with disability insurers who exited the market and stopped selling policies years ago, but sometimes active disability insurers also utilize third-party administrators.
Essentially, the third-party administrator’s “job” is to keep claim costs down for the company that hires them. In doing so, the third-party administrator is supposed to administer claims fairly; however, as you might imagine, the way to save the insurer the most money is to deny claims.
This can create bad incentives, as third-party administrators seek to secure more contracts with insurers and do not want insurers to drop them for paying out too many claims. As a result, in our experience, third-party administrators are typically more aggressive when investigating and vetting claims.
2. Do Ohio National disability policies for physicians have “true” own occupation disability definitions?
While Ohio National policies sold to physicians are often marketed as “own occupation” policies, they may not, alone, be “true own occupation” policies, as our disability attorneys define it. In our estimation, a “true” own occupation policy allows a totally disabled physician to collect total disability benefits and earn income in a different, unrelated profession.
While Ohio National does have “own occupation” coverage, not all Ohio National policies provide “own occupation” coverage for the entire benefit period. For example, the base policy definition of Total Disability may state that after a certain period of time (usually 2 years) you are only totally disabled if you are “not able to do the substantial and material duties of any occupation for which you may reasonably be expected to engage in because of education, training or experience” (emphasis added). In other words, it starts out as an own occupation policy, but changes after a certain period of time.
Ohio National does offer a rider, usually called an Occupation Rider, that modifies the base policy definition and can extend the own occupation period. However, even this rider can contain limitations and may only provide total disability benefits if the policyholder is not working at all. For example, the new definition of total disability may be along these lines:
You are Totally Disabled or have a Total Disability if due to Injury or Sickness:
(a) you are not able to perform the substantial and material duties of Your Regular Occupation;
(b) you are not engaged in any other gainful occupation; and
(c) you are receiving treatment on a regular basis from a Physician which is appropriate for the Sickness or Injury causing the Total Disability.
Under such a provision, the own occupation part of the definition extends for the entire benefit period; however, there is a caveat—you cannot be engaged in “any other gainful occupation.”
Accordingly, if you are a physician with an Ohio National policy it is very important to review your policy carefully to ensure that it meets your expectations of coverage. Even if it has “own occupation” language in parts, you must consider the whole to determine the full extent of coverage, and any relevant limitations.
3. As a physician, how do I go about filing a disability claim under an Ohio National disability policy?
In order to file an Ohio National disability claim, you must submit the proof of loss required under your Ohio National policy. Most Ohio National policies require this proof to be submitted in writing and within a certain time frame—typically within 90 days from the date of loss.
Ohio National allows claims to be initiated online, via Ohio national’s website, or by calling in to a number on their website.
If you call in, our attorneys have observed that Ohio National/its third-party administrator 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.
If you apply online, it is important to answer each question carefully and keep a record of what you submit. The initial proof of loss forms set the foundation for your claim, and you should not finalize or submit them unless you understand the ramifications of the type of claim you are making (partial v. total, etc.) and the date of disability you have selected (which can determine eligibility for benefits, and if you are even covered at all under an employer-plan).
4. Ohio National wants me to undergo an Independent Medication Examination (IME) to establish that I cannot practice as a physician. Do I have to do this?
Most disability insurance policies, including Ohio National policies, include provisions that allow them to request that an insured undergo an independent medical examination (IME) at the insurer’s request (and expense). Language about what types of examinations can be requested vary by policy. An example of an Ohio National provision is as follows:
While Income is to be paid, we may require that you be examined by a Physician of our choice. This will be done at our expense and at a reasonable time. If you refuse, Income stops.
This provision is notable because it explicitly says that benefits will cease if you refuse to undergo an IME – no matter how supportive your treating provider and medical records have been in confirming your disabling condition.
Unfortunately, IMEs are often ordered by insurance companies in an attempt to challenge, offer conflicting opinions, and/or discredit your treating provider/medical records. An experienced disability insurance attorney can ensure that an IME is conducted within the bounds of the policy, verify an examining doctor’s credentials, record and/or accompany you to the exam, and review the final report for accuracy.
If you do not believe an IME is warranted, an experienced disability attorney can evaluate the situation and determine if there are available alternatives that do not risk putting your benefits in jeopardy.
5. Ohio National is asking for my medical practice’s financial records. Do I have to provide them?
Many physicians are surprised at the scope of financial information that is required, particularly at the outset of a disability claim. However, this is a normal part of the process, and most policies, including Ohio National policies, expressly provide for this type of investigation in the policy contract.
For example, the proof of loss provision might state, in relevant part, that:
[Ohio National] may also require, as part of the proof of loss of earnings, the insured’s income statements, copies of state and federal income tax returns, audit reports, payroll records, accountant’s statements and any other records which contain the facts we need.
This requirement will also apply to the records of your business where you own any portion of a business in which you provide personal services.
That being said, not all financial information is relevant or needed to fairly evaluate a disability claim. For example, the scope of financial information needed to calculate partial/residual disability benefits is generally broader than the scope of financial information required to evaluate a total disability claim. An experienced disability attorney can review the relevant provisions and evaluate whether Ohio National’s requests are appropriate under the circumstances.
6. What types of physician disability claims are most often challenged/denied by Ohio National?
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 physician claims 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 physician. Others have mental health conditions (anxiety disorder, panic attacks, PTSD) that cannot be verified by a single, definitive objective test.
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 Ohio National 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 physicians’ disability claims include:
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- The timing of the claim (particularly in situations where a disabling condition is slowly progressive);
- Claims made by physicians with multiple sources of income, some of which may continue post-disability;
- Claims made by physicians who have taken an active role in office/hospital administration or are involved in non-clinical work;
- Claims involving alleged preexisting conditions;
- Claims where the underlying condition is difficult to diagnose or diagnosed by exclusion;
- Claims involving multiple co-morbid conditions;
- Claims involving conditions that are irregularly and unpredictably disabling;
- Claims involving pain/musculoskeletal conditions;
- Claims involving mental health conditions; and
- Claims involving recommendations for or against certain treatments or surgery.
7. Will Ohio National recognize my occupation/medical specialty?
Often, as part of their definition of total disability, Ohio National policies will include language stating that the policyholder will be Totally Disabled if “you are not able to perform all or the substantial and material duties of your regular occupation at the start of your Total Disability.” This may seem straightforward, but a policyholder’s regular occupation can become a point of contention and, in some cases, must be litigated.
For example, in Johnson v. Ohio National Life Assurance Co., No. WD-12-029 (Ohio Ct. App. Jan. 17, 2014), the plaintiff, Dr. Johnson was an OB/GYN from 1993 through May 2007, with a variety of employers over that time frame. From May to October 2007, he took time off but was unable to find employment in the OB/GYN field when he wanted to return, although he was actively looking for it. From October 2007 through March 2008, he worked on a temporary basis at a clinic, filling in for other doctors as needed. He also worked part time as a physician at an Urgent Care clinic (where he did not perform OB/GYN-related duties).
In June of 2008, Dr. Johnson saw an internal medicine specialist with complaints of joint pain, swelling and stiffness in his hands, along with a rash. Lab tests revealed significant inflammation of the hands and Dr. Johnson was referred to a rheumatologist, who he first saw on November 14, 2008. He was diagnosed as having psoriatic arthritis and on December 26, 2008 he submitted a claim with Ohio National for total disability. Although Ohio National agreed on the date of disability (June 2008) and that psoriatic arthritis prevented Dr. Johnson from practicing as an OB/GYN, they claimed his occupation at the time of his disability was that of an urgent care doctor—and that he was still able to do the material and substantial job duties of that profession.
The Courts agreed with Ohio National, finding that at the time of his disability, Dr. Johnson was working as an urgent care physician, even though he was a Board-certified OB/GYN and had been practicing in the specialty of OB/GYN for the majority of his career.
We’ve encountered physicians who inadvertently change their occupation by starting to work in another position or role, or otherwise modify their job duties, often as a way to accommodate a disability. Since regular occupation is often defined along the lines of “the occupation (or occupations if more than one) in which you are regularly engaged at the time you become Totally Disabled,” insurance companies will typically ask for CPT codes to identify the specific job duties you are doing at the time your disability started. In some instances, this might allow Ohio National to claim you are not working in your specialty and try to claim you are doing the very broadest job possible (thus making it easier to say you are still able to work).
8. I am physician who became disabled and then went back to practicing medicine, now I am disabled again. Do I have to start a new claim?
In some cases, a disabling condition may improve or abate to the point an insured is able to return to work, only for symptoms to later worsen to the point it is again no longer feasible to continue working. This is often referred to as a recurrent disability in disability insurance policies, and different insurers have different limits on how long the gap can be between periods of disability.
Ohio National policies are notable for (typically) allowing for a longer gap when considering recurrent disabilities. While some disability policies only allow you to link periods that are 3 or 6 months apart, some Ohio National policies provide that:
If Total Disability stops and then starts again within 365 days from the same or a related cause, the two periods of Total Disability will count as one. In such case, you do not need to meet a new Waiting Period, if already met, and the same Maximum Benefit Period will continue to apply to your Total Disability.
A recurrence of Total Disability from the same or related cause after 365 days counts as a new Total Disability. So does a Total Disability which recurs within 365 days from some other cause. A new Waiting Period and a new Maximum Benefit Period will apply when you have a new Total Disability. The Waiver of Premium provision will also apply anew.
Under this provision, if you become disabled by the same or a related cause, you won’t have to wait to receive benefits again, and your maximum benefit period won’t change. This can be very helpful if you have a condition that waxes and wanes, or you have a surgery or procedure that initially helps but loses effectiveness over time.
9. How do lifetime benefits work? I signed up for lifetime benefits, but Ohio National is saying I don’t qualify.
While Ohio National policies can be offered with the option of lifetime benefits, some policies add very specific parameters that must be met. Additionally, some policies provide different rules depending on whether the disability is due to Injury or Sickness. For example, the policy may state that:
If the Maximum Benefit Period shown on [the schedule page] is “Lifetime,” We will pay income for as long as Total Disability Lasts if Total Disability: (a) starts before age 55 due to Sickness; or (b) starts before Age 65 due to Injury.
While it may seem like the difference between an injury or sickness is clear-cut, it may not always be the case. For example, a physician may injure his or her back in an accident, only to find that the insurance company is arguing that the disability is actually due to sickness because previous medical records mentioned degenerative disc disease.
In our experience, when dealing with sickness/injury provisions, it is not uncommon for insurers, including Ohio National, to classify disabling conditions as sicknesses in order to avoid paying lifetime benefits. The legal rules for determining sickness versus injury can vary from jurisdiction, so if you believe that your claim has been misclassified, it is a good idea to speak with an experienced disability attorney and look into the rules that apply to your particular claim.
10. I’m a physician who is only able to practice part-time. Am I able to collect partial/residual disability benefits under my Ohio National policy?
Residual disability benefits (also called partial disability benefits) are part of many Ohio National policies marketed to physicians (often added as a rider). They provide partial benefit payments when a disabling condition prevents a physician from practicing fully.
In our experience, Ohio National’s definition of who qualifies for residual benefits is particularly complex in the industry. Rather than just looking at loss of income to determine eligibility, Ohio National considers the material and substantial duties of your job and whether you are still able to do them or to what degree you are able to do them. In addition, the requirements can shift as time progresses.
For example, initial requirements may read as follows:
For and during the entire Waiting Period: Either
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- you are not able to do one or more of the substantial and material duties of your regular occupation; or
- you are able to do the substantial and material duties of your regular occupation but for less time than is normally requires for those dues; AND either
- you have a Loss of Earning of at least 20% of your Monthly Earnings Before Disability; or
- you are not able to do one or more of the substantial and material duties which accounted for at least 20% of the time you spent in your regular occupation before your current disability started; or
- you are able to do the substantial and material duties of your regular occupation but for no longer than 80% of the time you formerly spend before your current disability started.
Then, after the next six months, the requirements can change to:
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- You have a Loss of Earnings of at least 20% of your Monthly Earnings Before Disability; or
- You are NOT able to do one or more of the substantial and material duties which accounted for at least 20% of the time you spent in your regular occupation before your current disability started; or
- You are able to do the substantial and material duties of your regular occupation but for NO longer than 80% of the time you formerly spent before your current disability started;
Then, after benefits have been paid for six more months, the requirements to receive benefits again shifts:
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- you have a Loss of Earnings of at least 20% of your Monthly Earnings Before Disability; and
- you are no longer required to have a loss of time or duties.
Consequently, if you have a partial disability claim with Ohio National it is important to review your policy carefully, and ensure that the correct metric is being applied to the relevant timeframe.
11. My physician disability claim was denied and I want to sue Ohio National. How long do I have to do that?
When bringing a lawsuit again an insurer for denied or terminated benefits, knowing when to do so can be important, so you don’t get barred by the statute of limitations. Laws include language about how long you have to sue under certain claims; however, knowing exactly when the clock starts on these time limits is not always straightforward, and rules vary from jurisdiction to jurisdiction.
For example, in Bennett v. Ohio Nat’l Life Assurance Corp., No. A166049, (Cal. Ct. App. June 20, 2023), the plaintiff, Dr. Bennett, an oral and maxillofacial surgeon, became disabled after being thrown from a horse at the age of 53. His policy stated that he would receive lifetime benefits if he became disabled due to injury, but only until age 65 if his injury was due to sickness. Despite his injury, Ohio National argued that the disabling condition was actually caused by degenerative disc disease.
Ohio National approved benefits starting on January 2014. However, on June 8, 2015, they notified Dr. Bennett that they had determined that his disability was caused by sickness and not injury. Ohio National then continued to pay benefits until Dr. Bennett reached 65 years old, terminating them on September 3, 2018. On August 13, 2019, Dr. Bennett sued Ohio National for breach of contract and breach of implied covenant of good faith and fair dealing.
Ohio National argued that the statute of limitations had run and that Dr. Bennett no longer had standing to sue, because the cause of action started when they issued “an unconditional denial of liability on June 8, 2015.” For his part, Dr. Bennett argued that the clock didn’t start running until all elements—including actual damages—had been met. Because Ohio National did not actually withhold benefits until he turned 65 and the claim was terminated, Dr. Bennet argued that the statute of limitations did not start running until September 3, 2018.
The Court ultimately found Dr. Bennett’s arguments sufficient to allow the lawsuit to move forward. However, as of this writing, a decision has not been reached on whether Dr. Bennett is actually owed benefits past the termination date.
Even so, this case illustrates the complexities that can arise when seeking to sue a disability insurance company. This case is also only an example of how one judge, in one jurisdiction handled these questions. Rules and holdings may vary from state to state, so it is important to speak to an experienced disability insurance attorney as soon as you think you may need to file a lawsuit for denied or terminated disability benefits.
12. Ohio National and I disagree with how my policy should be interpreted and they are trying to deny my claim. What can I do?
As you might imagine, not ever disability policy is a model of clarity and disputes can arise over the meaning of policy language. Whether or not you have an argument, and how strong it is, depends on a number of factors, including your jurisdiction’s rules for interpreting disability insurance contracts.
For example, in Machurek v. Ohio Nat. Life Ins. Co., 125 Neb. 35, 249 N.W. 81, 82 (1933), the plaintiff, Mr. Machurek worked in the automotive industry and became disabled after a shotgun accident left him without his left hand and part of his left arm. As part of his disability policy, he believed he was entitled to benefits because he was “wholly disabled by bodily injuries or disease” so that he “will be, presumably, thereby permanently, continuously, and wholly prevented from engaging in any occupation or employment whatsoever for remuneration or profit, or performing any work, and that suck disability then existed for not less than ninety days.”
Ohio National argued that Machurek was not disabled under the terms of his policy, but the court found this policy language ambiguous. As part of the Machurek’s evidence, he pointed to the fact that the authorized agent who sold him the policy and told him that the policy would pay if he was disabled until for 90 days, until he was well again (or for life if he never recovered). The Court explained that any ambiguities in policy language will be construed against the insurer, as the drafter of the policy and ultimately ruled against Ohio National.
While most states recognize this rule of policy interpretation, the specifics work differently in different jurisdictions, so you should always speak with an attorney before making any legal arguments in a lawsuit against your insurer. Further, while the representations made by the agent were noted in this case, now many insurers specifically include language in policies that representations made by agents are not binding. Accordingly, it is important to read your Ohio National policy carefully upon receipt to confirm that the provisions are clear, and that they truly reflect what any agent explained to you.
13. Ohio National’s doctor is claiming I can have surgery and go back to practicing as a physician. Can Ohio National make me have surgery?
Most disability policies include care requirements that must be satisfied in order to qualify for benefits. These provisions, at a bare minimum, require that you be receiving ongoing medical care in order to remain eligible for benefits. This is the part of the policy that insurers most commonly invoke if they believe that a policyholder should be considering or receiving surgery.
For example, in Tittsworth v. Ohio Nat. Life Ins. Co., 6 Tenn. App. 206, 207 (1927) the plaintiff, Mr. Tittsworth, was a farmer who suffered spinal injuries as the result of an accident. Physicians later told him that an operation was the only remedy for curing his disability. However, another physician indicated that, while the surgery would ultimately get him well, it would cause a loss of control of the bowels. Tittsworth refused to undergo the surgery and Ohio National ceased benefit payments.
In this instance, the Court found that there was no contractual obligation requiring Tittsworth to undergo the operation, and found in his favor. However, other jurisdictions have handled this question differently. It is a nuanced question that involves interplay between legal principles of policy interpretation and medical considerations specific to your disabling condition. Accordingly, if Ohio National is attempting to argue that you need to undergo surgery in order to be granted or continue to receive benefits, an experienced disability insurance attorney can help you navigate this scenario.
14. When should I contact an attorney about my Ohio National physician disability claim?
Physicians 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, physicians 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.
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 concerned that Ohio National 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 Ohio National Disability Insurance Cases
Bennett v. Ohio Nat’l Life Assurance Corp., No. A166049 (Cal. Ct. App. June 20, 2023).
Johnson v. Ohio National Life Assurance Co., No. WD-12-029 (Ohio Ct. App. Jan. 17, 2014).
Machurek v. Ohio Nat. Life Ins. Co., 125 Neb. 35, 249 N.W. 81, 82 (1933).
Tittsworth v. Ohio Nat. Life Ins. Co., 6 Tenn. App. 206, 207 (1927).
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