Standard Disability Claim Tips for Physicians
Our law firm has extensive experience filing and litigating Standard disability claims for physicians. Our attorneys understand how Standard operates and what it takes to file a successful Standard disability claim, and are happy to set up a free consultation to discuss your particular Standard claim.
Below are some answers to the most common questions our attorneys receive from physicians about the disability claim process, generally, and their Standard disability benefits, specifically.
Table of Contents
3. I am a physician with both physical and mental health conditions that make it difficult/impossible for me to practice medicine. Will Standard deny my claim/try to limit my disability insurance benefits?
1. Are the disability insurance policies Standard issues to physicians “true own occupation” policies?
While Standard 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 Standard does have “own occupation” coverage, our attorneys have found in some base policies that coverage only lasts for a limited period of time. For example, the policy definition of Total Disability might read:
Because of Your Injury or Sickness:
For the first 12 months of Disability, You are unable to perform the substantial and material duties of Your Regular Occupation; after the first 12 months of Disability, You are unable to perform the substantial and material duties of Your Regular Occupation and You are not engaged in any other gainful occupation for which You are or may become qualified by reason of education, training or experience . . .
Under such a provision, Standard’s definition of disability changes after the initial 12 months of disability. A physician who returned to work in a different capacity would likely have his or her total disability benefits terminated at the end of the 12-month period.
Depending on the Standard policy in question, there may be other benefits available at that point—such as residual/partial disability benefits. But this is clearly not a “true” own occupation policy. Our disability attorneys note that, as many physicians will need to rely on both their disability benefits and income from another source to maintain pre-disability income levels, this can be a problem for disabled physicians.
That being said, Standard policies do have riders that can be added that change this base definition. In Standard policies, this is most often called an “Own Occupation Benefit Rider,” and this rider changes the base policy’s definition of Total Disability to eliminate the 12-month rule and extend the “own occupation” definition to the end of the max benefit period.
Another wrinkle to watch out for is Standard’s “Return to Work Responsibility” provision, more likely to be found in Standard employer (ERISA) policies. This provision requires you to work if you are capable of earning a certain percentage of your prior income (typically 20%) and, if you don’t, Standard can stop paying benefits. As you might imagine, this provision can give rise to disputes in an area that can be difficult to address and may need to be litigated (i.e. capacity to earn).
Accordingly, whether you plan on working in a new occupation or not working at all, it is important to carefully review your Standard policy to determine if that plan is consistent with your policy’s requirements.
2. I am a physician with anxiety/panic attacks/major depressive disorder. Can I file a mental health claim under my Standard policy? Do I need the assistance of an attorney?
Physicians, in particular, can be prone to mental health conditions like anxiety/panic attacks, given the demanding nature of the profession, the pressure to not make mistakes or cause the patient undue pain, and the fact that many of their own patients have anxiety about seeing physicians.
If you have a Standard policy, the answer is “it depends.” If you have a Standard policy that was issued more recently, it may have a provision that limits recovery for mental health conditions to a shorter benefit period (most often 24-months).
Additionally, mental health disability claims can be challenging, as they are largely based upon subjective symptoms. In our experience, our law firm has found that while it is not impossible to collect disability benefits for anxiety, depression or other mental health conditions, if you are a physician filing that sort of disability claim it is typically a good idea to at least consult with an experienced disability attorney before filing your claim.
3. I am a physician with both physical and mental health conditions that make it difficult/impossible for me to practice medicine. Will Standard deny my claim/try to limit my disability insurance benefits?
As discussed above, many Standard policies have a mental disorder and/or substance abuse limitation, usually capping benefits at 24-months.
Many physicians have degenerative physical conditions, such as cervical and lumbar DDD. This can result in other problems, such as radiculopathy and numbness in your extremities, including the hands you use to perform procedures or surgeries. Initially, this numbness can come and go and be very stressful for physicians working with patients in such an environment.
In some cases, this can lead to a situation where a physician is both suffering from a physical health limitation and is experiencing anxiety in the dental office as a result.
Conversely, you may have a condition, such as dysautonomia/autoimmune disease that flares and manifests with physical symptoms if you are stressed or anxious, and working as a physician may exacerbate your stress levels.
As such a physician, you may be wondering, what happens if you have both a mental health condition and a physical one? Historically, our disability attorney have noted that Standard has attempted to enforce the 24-month limitation for mental health conditions, particularly if they have room to argue that the physical condition is “caused or contributed to” by a mental disorder.
This is what happened in the case of Kitterman v. Standard. Dr. Kitterman suffered from depression, migraines, and anxiety. Standard initially paid disability benefits, but terminated Dr. Kitterman’s disability claim after 24-months, arguing that the migraines were a result of Dr. Kitterman’s major depression and therefore not excluded from the limitation.
Dr. Kitterman was able to produce letters from his doctors indicating that, in their opinion, the migraines were debilitating in-and-of-themselves. Standard’s attorneys argued that these letters were not backed up by the underlying medical records, and they obtained their own medical consultant to conduct a review. Dr. Kitterman sued the Standard and, ultimately, the court sided with Dr. Kitterman.
While Dr. Kitterman obtained a favorable result, these disability cases are very fact-specific and the outcomes depend on the underlying disabling conditions. If you are concerned about Standard unfairly applying a mental health limitation provision, an experienced disability attorney can review your situation and help you determine if your particular situation falls within or outside of your policy’s exclusionary language.
 Kitterman v. Standard Ins. Co., No. 6:09-cv-06294-TC, 2011 WL 5374565 (D. Or. Apr. 7, 2011).
4. My Standard policy has an “other limited conditions” provision. What does this mean?
Our attorneys have found that Standard policies expand further, beyond mental health conditions, and encompass a larger spectrum of “other limitation conditions” that are subject to the policy’s 24-month limitation.
One example that is particularly noteworthy for physicians is “musculoskeletal” conditions—one of the most common causes of disability.
Most of the time, if “musculoskeletal” conditions are excluded, there will be certain exceptions to that exclusion—for example “radiculopathy” and “herniated discs” are a few of the more common exceptions.
While this might, initially, seem like sufficient protection for a physician claim, it is important to remember that disability claims involve ongoing, monthly determinations of eligibility for disability benefits, and not just a single determination of disability at the outset. This can be significant in disability claims that hinge on a disabling condition that must be fit within very particular parameters to avoid exclusions that terminate benefits or limit recovery.
As an example, consider the case of Zall v. Standard. In this case, Dr. Zall’s physician found him disabled due to a herniated disc and intermittent radiculopathy. Although it was arguably a musculoskeletal disorder, Standard approved the claim under the “herniated disc” and “radiculopathy” exceptions noted above.
However, after paying the claim for a period of time, Standard conducted a medical review and determined that Dr. Zall’s later medical records no longer established that the numbness in his hands remained attributable to the herniated disc/radiculopathy established at the outset of the claim. In this instance, the Court sided with Standard, showing how hard it can be to continuously qualify for an exclusion to an “other limited conditions” provision.
If your Standard policies have an expanded “other limitation conditions” that are subject to the policy’s 24-month limitation of benefits, it would be prudent to speak with an experienced disability insurance attorney before filing your claim.
5. I’m a physician and my doctors support my disability claim already. Is it legal for Standard make me undergo a medical examination to qualify for benefits?
Most disability policies, including Standard disability policies, contain provisions that allow insurers to require medical examinations to receive and/or continue to qualify for benefits.
Some insurers simply state the company “may require” an insured to undergo an exam.
Our attorneys have found that other policies, such as many issued by Standard, go further and hinge the payment of benefits on participating in these medical exams. One example of a Standard provision reads as follows:
We can have Physicians or specialists examine You, at Our expense, as often as reasonably necessary while You claim to be Disabled. Any such examination will be conducted by one or more Physicians or specialists We choose.
We may defer or suspend payment of benefits if: (1) You fail to attend an examination; or (2) You fail to cooperate with the person conducting the examination”
This stringent provision is notable for a few reasons. First, the provision allows Standard to request a medical exam as often as “reasonably” necessary. Second, it explicitly states that benefits can be withheld for failure to attend or lack of cooperation.
An experienced disability attorney can vet whether Standard’s request for a medical examination is “reasonable” and appropriate in your claim. In some instances, an exam may be necessary but it is still important to have an attorney determine whether the scope of the exam is appropriate, and vet whether the doctor chosen to conduct the exam is unduly biased or otherwise unqualified to conduct the exam.
Additionally, it is important to note that we are now seeing some Standard policies stating that Standard can, during the initial waiting period, determine an “appropriate specialty” for your condition. Under these policies, Standard can then terminate benefits if you do not receive ongoing care from a physician in that specialty. This is an important policy requirement that should not be overlooked, as failure to see the right type of doctor can not only result in Standard determining that an in-person examination is necessary, but could potentially be a basis for a claim denial and/or retroactive demand for repayment of previously-paid disability benefits.
6. My Standard disability policy has an Allocation of Authority provision. What does this mean? Have your disability attorneys dealt with this type of provision before?
An Allocation of Authority provision is one that our disability attorneys have seen in several Standard individual disability insurance policies (and not one we see commonly with other providers of individual policies). The provision purports to give Standard great leeway in interpreting and adjudicating claims. One example of such a provision reads:
Except to those functions which the policy specifically reserves to the Owner, We have full and exclusive authority to control and manage the policy, administer claims, interpret the policy and resolve all questions arising in the administration, interpretation, and application of the policy.
Our authority includes, but is not limited to:
1. The right to resolve all matters when a review has been requested;
2. The right to establish and enforce rules and procedures for the administration of the policy and any claim under it; and
3. The right to determine:
a. Eligibility for insurance;
b. Entitlement to benefits;
c. The amount of benefits payable; and
d. The sufficiency and amount of information we may reasonably require to determine a, b, and c above.
Subject to the policy’s Review Procedure, any decision We make in the exercise of Our authority is conclusive and binding, unless challenged in a legal action. This provision will not restrict Your right to challenge a denial of benefits in a legal action.
Whether, and to what extent, this provision is enforceable depends on a number of factors, including the underlying state law that might apply and whether the policy might be subject to an ERISA safe-harbor analysis.
In our law firm’s experience, Standard does not invoke this provision on every claim; however, that may be a function of the fact that we are attorneys and are aware that the power of this provision can be challenged and limited in certain circumstances.
Regardless, at a minimum, it communicates Standard’s desire to have complete control over the process and an unwillingness to consider positions that differ from Standard’s claim determinations.
Accordingly, when dealing with Standard, it is important to present your disability claim properly and fully during the first filing, with the assistance of an attorney, to avoid a denial and Standard digging its heels in and using this provision to refuse to consider additional information or alternative positions (absent litigation).
7. My Standard claim for disability benefits was denied/cut-off. What do I do next? Do I need a law firm able to help me?
Our law firm has noted that another aspect of Standard policies that is somewhat unique in the industry is that Standard writes-in a formal review timeline into many of its policies. Below is an example (but may not exactly match the timeline/deadlines in your particular policy).
If We deny all or part of Your claim, You may request a review. You must make the request within 180 days after receiving notice of the denial. Your request must be in writing.
If We deny Your claim:
1. You may send Us written comments or other items to support Your claim; and
2. You may review any non-privileged information that relates to Your request for review.
We will review Your claim promptly after We receive Your request. We will send You a notice of
Our decision within 60 days after We receive Your request. If special circumstances require an extension We will send it to You within 120 days. We will state the reasons for Our decision; and
We will refer You to the relevant parts of the policy.
As you can see, once a claim is denied there are contractual deadlines for challenging denials, in addition to other legal deadlines that might apply, such as statutes of limitations.
As with the “Allocation of Authority” provision, in some instances there may be legal arguments that the deadlines don’t apply in every situation, or that certain legal principles carve out exceptions under certain circumstances. However, it can be difficult to prevail in such circumstances and it is far better to challenge denials with assistance of an experienced attorney within the appropriate timelines and frameworks to—if nothing else—avoid creating additional points of dispute on your claim.
Accordingly, if your Standard disability claim is denied, and you do not already have a disability attorney, you should speak with one immediately to ensure that the attorney has sufficient time to respond to the denial within the applicable framework of deadlines.
8. Standard conducted a paper-only review of my medical records and then denied my disability claim for benefits. Can they do that? Is it legal?
As we discussed above, Standard often has stringent medical examination provisions, which give them the right to require that an insured undergo a medical examination by the physician or specialist of Standard’s choosing.
But what happens if Standard chooses not to exercise this right and instead bases its claim decision solely on a paper review of your medical records? Can they still deny your disability insurance claim?
The short answer is yes, there is not a hard and fast rule that disability insurance companies must have a claimant undergo an in-person medical examination. For example, if the disability claim is clearly untimely or meritless, it would make sense for the insurer to decide to avoid incurring that expense.
However, our attorneys have found not all disability claims are that clear-cut, and if the underlying claim involves legitimate disputes about the nature of the disabling condition, or the resulting restrictions and limitations, courts do consider whether an in-person review should have been conducted by the insurance company.
One such example is the case of Whalen v. Standard. Whalen filed a disability insurance claim with Standard for cervical and lumbar spine issues following an automobile accident, but Standard denied his claim.
In evaluating whether Standard acted appropriately, the Court turned to several factors, including whether Standard had conducted and in-person interview and whether Standard provided its independent experts with all relevant information about the disabling condition.
In this case, Standard retained two experts. The first indicated that, while he did not believe that Whalen was disabled from working, he also stated that he needed “further information from the neurosurgeon” to determine a reasonable duration of impairment/disability. However, Standard did not follow up with the neurosurgeon.
The second reviewer also looked at Whalen’s records, but noted that most of the primary care notes were hand-written and largely illegible. The Court pointed out that, again, “[n]o efforts were made [by Standard] to supplement the record prior to [the reviewing doctor] issuing her final opinion of Plaintiff’s [disabling] condition.”
The Court pointed to both of these facts as showing that Standard had not provided its medical reviewers with all the relevant evidence needed to fully evaluate Plaintiff’s condition and entitlement to disability benefits. The Court weighed the facts that Standard had not had Whelan medically examined in person, had not provided all relevant evidence, and had a conflict of interest to determine here that Standard had abused its discretion.
The Whelan case is also an example of the insurance company’s medical reviewers cherry-picking from the medical records in their reports and conclusions (i.e. pulling out statements that support a denial, while ignoring statements in support of payment).
In Whelan, one of Whelan’s doctors noted an estimated return date to work; however, he also noted that the actual return to work date was “undetermined at this time.” Standard focused only on the estimated return to work date, and used that to find the claim benefits were no long payable after that date.
In sum, our attorneys have found that while Standard doesn’t have to conduct a medical examination, they also don’t have the right to provide their independent medical reviewers with an incomplete record, or the right to selectively focus on only a portion of an insured’s medical records.
If you believe that Standard did not properly consider the medical support for your disability claim, it is a good idea to at least consult with a disability attorney about your claim, to determine if further legal action is warranted.
9. Do I need to hire an experienced Standard disability attorney to file my claim to help ensure that I get paid benefits?
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 disability attorney address any concerns that the Standard may have over the course of the investigation itself, so that you are not placed in a position where disability benefits have been cut off/denied, you are not working and your only option is a lawsuit.
In our law firm’s experience, the most common areas where complexities can arise in physician’s disability claims include:
- The timing of the claim (particularly in situations where a disabling condition is slowly progressive or the where the physician works too long in spite of his/her condition);
- 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 multiple policies with different insurers;
- Claims initially handled by the physician individually, without legal representation;
- Claims where the physician has already submitted to an interview under oath or an insurance company medical exam;
- Claims involving an 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.
10. When should I contact an attorney about my Standard 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 Standard 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.