Why Was My Claim Denied?
What Do I Do Now?

A disability insurance claim can be denied for a variety of reasons. Some reasons are legitimate, and some are not. This can be especially true for dentist and physician claims that can be targeted for denial simply because of the policies’ high benefit amounts and how much money is at stake.

Knowing the specific reason or reasons for a disability insurance claim denial is critical to deciding what your next step should be. Because of this, some states, including Arizona, have adopted laws that require insurers to provide you with timely information explaining the basis for a denial. In both Arizona and California, an insurer that denies a claim must provide a reasonable explanation for the denial based on the terms of the policy, the facts, or the applicable law.[1]  Some states’ laws also require that the notice of denial must be in writing, must reference any specific grounds for denial, and must explain how those grounds specifically apply to your claim.[2]  Failure to provide an explanation could lead to a finding that your insurer acted in bad faith.

When you receive the explanation of denial, chances are it may be confusing to understand. Even if an explanation is provided, it may still warrant a finding of bad faith if the explanation fails to clearly communicate the rationale behind a denial[3] , or the denial was founded on an improper bases (e.g. a biased medical exam).

If you have already filed and your insurance company has wholly or partially denied your claim, there is often a short window of time in which to act if you wish to preserve your claim. If you have filed a claim, or you are facing a denial from your insurance company, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.

[1] A.R.S. § 20-461(A)(15) (2018); Cal. Ins. Code § 790.03(h)(13) (2018).

[2] Cal. Code Regs. tit. 10, § 2695.7 (2018).

[3] See, e.g., the California case of du Mortier v. Mass. General Life Ins. Co., 805 F.Supp. 816, 823 (C.D. Cal. 1992).

 

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Disability Insurance Basics:
Business Overhead Expense Policies

We have previously discussed how important it is to periodically review your disability insurance policies to make sure your coverage and benefit amounts reflect where you are at in your career. Most physicians and dentists purchase a disability policy at the beginning of their careers. However, as time goes on, their financial situation, family life, and practice can evolve into something completely different that requires a different level of coverage.

A “business overhead expense policy” is one type of policy that many doctors consider when they have reached the point in their career where they are purchasing their own practice. These policies are designed for practice owners and cover short term business-related expenses. If you become disabled, these policies can help you cover day-to-day operations for a certain period of time (typically 1-2 years) to give you time to heal and return to practicing (or, alternatively, give you time to sell the practice, if you have a condition that is more permanent in nature and are having difficulty finding a buyer).

Like any disability insurance policy, each BOE policy is unique. Some common covered expenses can include:

  • Rent
  • Real estate and property taxes
  • Utilities
  • Laundry, janitorial, maintenance services
  • Licensing fees and dues
  • Insurance premiums
  • Billing and collection fees
  • Taxes
  • Interest on debts
  • Depreciation or scheduled installment payments on principal of debt
  • Rent or lease expenses on items such as furniture, equipment, other assets used in the practice
  • Normal, necessary, and customary fixed expenses
  • Salary(ies) of substitute employee(s) – this can be especially attractive to sole practitioners, who may need to employ another dentist or physician to keep their practices in operation

Keep in mind that a business overhead expense policy will typically not cover your lost wages, and typically only last for a limited time, so you will need to have other policies to protect your own monthly income in the event of a long-term disability. Some business overhead policies also contain a list of costs that are not covered by the policy, such as:

  • The cost of goods or merchandise
  • Implements of your profession
  • Premiums waived due to disability
  • Income or self-employment taxes
  • Purchases (such as equipment) after the date of disability
  • Prepayment or advance payment of covered overhead expenses
  • Salaries for employees that are also family members

Consequently, it is important to read your policy carefully so that you have a clear understanding of the expenses that are covered and the expenses that are not.

These are just a few examples of things to be aware of if you have or are considering a Business Overhead Expense policy. These policies are not all identical, and they are updated frequently. Your policy may or may not include the provisions mentioned above. If you are considering filing a disability claim, you should consult with an experienced disability insurance attorney to learn more about your policy and any potential issues related to your particular claim.

 

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Why Does the Insurance Company
Want My CDT/CPT Codes?

When filing a claim, many dentists and doctors think that they will merely have to submit a form giving notice of the claim and have their doctor sign something verifying they are disabled. Most don’t realize or expect the breadth of their insurance company’s investigation and one thing that often surprises dentists and physicians is the company’s request for their CPT or CDT codes. Most newer insurance policies contain language that expressly allows insurers to request financial and practice information like this, and there are several things they are looking at when they request these codes.

Changes to Your Occupation/Job Duties

Most own occupation policies say they will consider you to be totally disabled if you can no longer do the “material and substantial” duties of your occupation. Insurance companies will look to CDT/CPT codes to see if you have changed or limited the types of procedures you do, and thus potentially modified your job description, prior to filing the disability.

When you file a claim, the company will typically be looking at what your duties were immediately prior to your reported date of disability. If you stopped performing more difficult procedures for an extended period prior to your date of disability, many companies will try to narrowly define your occupational duties as something less than what you perceive your occupation to be. For example, they might characterize you as a “dentist who doesn’t do root canals,” or a “surgeon who doesn’t do hip surgeries.”

Changes in Hours/Production

Similarly, reducing your work hours prior to filing a claim can impact your ability to collect. While your CDT/CPT codes won’t necessarily directly show the hours and days worked, they will show drops/increases in production and prompt follow-up questions from the insurance company if the production numbers don’t add up.

Additionally, some policies require an insured to work a certain number of hours a week, and cutting back on hours for an extended period of time prior to filing a claim could also lead your insurance company to classify your occupation as “part-time.” This is problematic because it becomes much harder to prove you can’t work part-time, versus proving you can’t work full-time.

Reviewing and understanding your policy, including what types of information your insurance company will request, is an important part of any transition plan. If you are considering filing a disability claim, you should consult with an experienced disability insurance attorney to learn more about your policy and any potential issues related to your particular claim.

 

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Unum Study Shows the Prevalence of
Mental Illness in the Workplace

In prior posts, we’ve discussed the mental health challenges physicians and dentists can face due to their high-stress and high-responsibility work environments. We often see doctors who are wondering if they can successfully file a claim based on a mental health condition, but are also reluctant to ask because they are concerned about what their colleagues/families/friends with think. Often, they feel like they are the only one struggling with these challenges but, in reality, they are not alone.

Unum, one of the largest disability insurers in the U.S., recently released a report[1] that looks at mental health challenges in the U.S. workplace. The report found that mental illness was one of the top causes of worker disability in the United States, with 62 percent of missed work days attributable to mental health conditions. Of those employees with mental health conditions:

  • Forty-six percent of those who missed work took an extended period of time off (over a week)
  • Two-thirds of employees with mental health issues went to work while experiencing symptoms (and reported a drop in productivity)
  • Forty-two percent of those who came to work were experiencing suicidal feelings

Despite the prevalence of mental health conditions (including anxiety, depression, and PTSD), sixty-one percent of the surveyed employees indicated that they felt there was a social stigma around those with mental health issues.

Although this study looked at data from employees, human resource professionals, mental health professionals, and research organizations that was not specific to the medical field, it is widely accepted that doctors are among those most likely to experience burnout during the course of their careers, with symptoms that overlap those of depression, anxiety disorder(s), and/or other mental health conditions. Unfortunately, stigma in the workplace and presenteeism may make doctors even more likely to ignore the symptoms of a mental health condition, push themselves to keep working, and/or avoid seeking support on the job and/or through treatment.

Ironically, we often see Unum (and other insurance companies) target mental health claims made by professionals due to the higher benefit amount of their policies and the more subjective nature of symptoms related to mental health conditions. They may pressure your treating provider for a return to work date, conduct surveillance to catch you in a happy moment that can be taken out of context, or have their in-house doctor question your course of treatment.

Further, many disability insurance policies now have substance abuse and mental health limitations provisions, which limit the amount of time a policyholder can collect for these types of conditions (usually to 24 months).  For these reasons, it is very important for physicians, dentists, and other professionals to have an awarenes of the challenges that may arise when filing a claim and understand what their policy says.

If you are considering filing a disability claim based on a mental health condition, you should consult with an experienced disability insurance attorney to learn more about your policy and any potential issues related to your particular claim.

[1] Unum report explores mental health challenges in U.S. workplaces, Unum, March 27, 2019.

 

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Arizona Now Matches
Other States’ Professional Licenses

In April 2019, Arizona Governor Doug Ducey signed legislation making Arizona the first state to match other states’ professional licenses. This allows individuals whose jobs require licenses, including dentists and physicians, to automatically receive a license in Arizona, provided they held a similar license in another state for at least one year with no disciplinary action. Under the new law, Arizona’s licensing boards can only test for Arizona-specific information.

Proponents say it paves the way for skilled workers to relocate and bring their expertise to Arizona, without added expense and time delays before they can start working. Further, those in support say it could help to address the medical and nursing shortages in Arizona. Those against the bill cited potential public health and safety concerns, arguing that some states have easier licensing requirements and that new arrivals will compete with those currently practicing in Arizona, potentially driving down wages.

Other states have taken less sweeping steps to ease licensing requirements for relocating professionals, such as reciprocity agreements between states and, in the case of Utah, accepting licenses from other states, but only for military spouses.

Currently, the American Medical Association advises physicians, in general, to plan to wait 60 days between the date an application is submitted and the date a license to practice medicine is granted. The American Dental Association, while supporting individual state’s rights to regulate licensure for dentists, has also adopted policies on licensure issues, including the freedom of movement for dentists and standardization of clinical licensing examinations.

At the bill’s signing in Phoenix, the governor said an expected 100,000 relocating professionals will benefit from the legislation in 2019. Attorneys, private investigators, and security guards are exempt from the new legislation and are still required to complete the Arizona licensing process. As of this writing, the law is expected to go into effect August 2, 2019.

 

Sources:

Jonathan J. Cooper, Arizona becomes 1st to match out-of-state work licenses, Associated Press, April 10, 2019.

Lurissa Carbajal, Arizona becomes the first state to recognize all out-of-state occupational licenses, Cronkite News, April 10, 2019.

Howard Fischer, Ducey signs bill for state to recognize out-of-state-license, Arizona Capitol Times, April 10, 2019.

American Medical Association, Obtaining a medical license

American Dental Association, Licensure Overview

 

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Can You Collect On Your Specialty Specific Policy?
A Case Study

Disability claims filed by professionals can be complex, particularly when the dentist or physician’s underlying occupation is a specialty specific field.

If the claim involves a discrete practice area, disability insurers may use that as an excuse to drag their feet when making a claims decision. For example, they may make repeated requests for employer questionnaires, financial information and/or vocational examinations, among other things. Then, as time goes on, the financial pressures of being left with no income build, prompting some doctors to consider a return to work even though it’s not safe for them to be practicing on patients. Other doctors with specialty-specific policies reason that they can return to work in a different field and expect to receive their benefits as a supplement to the new job, only to find that their insurer disagrees that they were, in fact, a specialist, and refuses to pay total disability benefits.

This is what happened to Joanne Ceimo, M.D., a former invasive cardiologist from Scottsdale, Arizona who practiced at Banner Boswell Medical Center in Sun City, Arizona.[1] Dr. Ceimo had an own occupation policy and was practicing within her medically recognized specialty of invasive cardiology. In 1994, doctors diagnosed Dr. Ceimo with cervical degenerative disc disease, which made it increasingly difficult for her to perform surgeries and prevented her from performing on call duties. Eventually, she was forced to stop performing surgeries as well and instead began practicing general cardiology.

In her mind, Dr. Ceimo’s new job as a general cardiologist was substantially different than her prior job as an invasive cardiologist. However, Dr. Ceimo ultimately had to sue General American, along with Paul Revere and Provident (the other insurance companies administering her claim) for the benefits she was due under her policy. She filed her disability insurance claim in 1995 and, after a long, drawn-out claim investigation, was eventually denied benefits in 1998. Due to the long delay, Dr. Ceimo was forced to continue working as a general cardiologist to meet her expenses, even though it was bad for her health and working made her pain worse.

When they denied her claim, the companies asserted that Dr. Ceimo was not a specialty cardiologist because she had only spent six to ten hours on surgeries per week. The companies then stated that her occupation before her date of disability was that of a general cardiologist, and concluded she was not eligible for total disability benefits because she continued to practice in that capacity. In making this argument, the companies ignored the fact that Dr. Ceimo had practiced invasive cardiology from when she was licensed by the Arizona Medical Board in 1982 through the onset of her disability in 1995. The companies also failed to mention that their own medical records review classified Dr. Ceimo as an “invasive cardiologist.”

Dr. Ceimo and her lawyers filed a bad faith lawsuit in the District of Arizona against General American, Paul Revere and Provident.[2] In addition to arguing that the companies improperly interpreted her specialty, Dr. Ceimo and her attorneys also asserted that the companies improperly relied on biased in-house medical consultants and internal company practices geared towards denying high-dollar physician claims like Dr. Ceimo’s. The case ultimately produced a large verdict in favor of Dr. Ceimo, with almost $6.7 million in consequential damages, but it took nearly a decade of fighting before she obtained the benefits she was due under her policy.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your company is improperly delaying a claims determination and/or targeting your claim for denial or termination, an experienced disability insurance attorney can help you assess your claim and determine what action, if any, needs to be taken.

[1] See Ceimo v. Gen. Am. Life Ins. Co., 2003 WL 25481095 (D. Ariz. Sept. 17, 2003).

[2] They alleged that all three companies were licensed to do business in Arizona, subject to Arizona’s bad faith laws and required to abide by the Arizona Unfair Claims Settlement Practices Act.

 

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Arizona’s Physician Shortage

A recent study published by the Association of American Medical Colleges (AAMC) found that the U.S. is facing a growing shortage of physicians—both those in primary care and specialty care—with an estimated expected shortage of between 46,900 and 121,900 by 2032.[1]  The shortage is likely due to a number of factors such as the increased costs of going to medical school, the long hours that doctors work, doctors facing disabling conditions that interfere with their ability to practice safely, and other distractions that interfere with their ability to focus on helping patients, like lawsuits and dealing with insurance companies/bureaucratic rules/red-tape.

Arizona is not exempt from this trend, with the AAMC ranking Arizona just 42nd nationwide in the number of active primary-care physicians per 100,000 people.  This, in part, is what prompted Nebraska-based Creighton University to expand its medical program and open a medical school in Phoenix (opening in the fall of 2021).  Creighton will continue partnering with Arizona-based St. Joseph’s Hospital and Medical Center (part of Dignity Health), District Medical Group, and the Maricopa Integrated Health System.[2]  Arizona’s two other medical schools, both based at the University of Arizona, are affiliated with Banner Health.

While expanding educational opportunities can be an important next step in addressing physician shortage, an upcoming Healthcare Breakfast Panel 2019 will also look additional issues surrounding the growing shortage, including how the shortage affects other healthcare physicians, patients and employers, how technology is being used in virtual medicine, and what experts see for the future.  The panel will also look at what the passage of Arizona Senate Bill 1354, an act appropriating money from Arizona state’s general fund (fiscal year 2019-2020) to Arizona graduate medical education programs, could mean for the state.  The panel is scheduled for June 20, 2019 and is sponsored by Health System Alliance of Arizona.

[1] New Findings Confirm Predictions on Physician Shortage, AAMC News, April 23, 2019.

[2] Greg Toppo, From Omaha to Phoenix, Inside Higher Ed, Feb. 13, 2019.

 

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Sickness or Injury?
Why Does it Matter?

Some disability insurance policies have different rules for a sickness versus injury.  These differences can prove quite significant when it comes to your maximum benefit period.

While the difference between an injury and sickness may, initially, seem clear-cut, if you have certain disabling conditions (such as degenerative disc disease or carpal tunnel syndrome) whether you have a disabling sickness versus injury can be a very nuanced determination. For example, when a particular event causes a slowly progressive disease to become suddenly disabling to the point a dentist or doctor can no longer work in his or her occupation, the final determination may have to be made by a court.

This is what happened in a recent case before the Arizona District Court.[1] Dr. Wood was an anesthesiologist who practiced in Page, Arizona within the Banner health system. Dr. Wood suffered from degenerative disc disease in his lumbar and cervical spine, but continued to practice (a common phenomenon among physicians and dentists called presenteeism). In 2015, he and a team of nurses lifted a patient from the operating table to a hospital bed—a routine maneuver that he had done thousands of times before. This time, however, the maneuver resulted in intense radiating pain in his spine and he found himself unable to work. Dr. Wood then filed a claim with his insurer, Provident, due to the disabling back condition.

While Dr. Wood felt his disability was caused by an accident, making him eligible for lifetime benefits under the terms of his policy, Provident classified his disability as a result of sickness, and maintained he was only eligible for 48 months of benefits. Dr. Wood sued Provident and the court had to determine what “injury” meant.

Fortunately for Dr. Wood, in this case, the Arizona judge determined that the policy had a vague definition of “injury” and ruled the provision should be interpreted in Dr. Wood’s favor. The court turned to precedent set by the Arizona Court of Appeals, finding that Arizona does not distinguish between ‘accidental means’ and ‘accidental results.’”[2] The court also noted the Arizona Supreme Court’s findings that “accident” must be read in light of common speech, usage, and understanding of the average man.[3]  In the end, the court found that, under Arizona law, Dr. Wood became disabled when performing the lifting maneuver and he was eligible receive lifetime benefits.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are unsure of how your policy interprets sickness versus injury, an experienced disability insurance attorney can help you interpret this language and apply it to your particular situation.

[1] See Wood v. Provident Life & Accident Ins. Co., 2018 WL 2416190  (D. Ariz. May 29, 2018).

[2] Id. quoting Central Nat. Life Ins. Co. v. Peterson, 529. P.2d 1213  (Ariz. App. 1975).

[3] Id. quoting Knight v. Metro Life Ins. Co., 437 P.2d 416 (Ariz. 1968).

 

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Edward O. Comitz and Michael F. Beethe Named
Southwest Super Lawyers for 2019

Ed Comitz and Mike Beethe, the founding members of Comitz | Beethe, have both been named Southwest Super Lawyers for 2019.  This is the eighth consecutive year that Mr. Comitz and Mr. Beethe have been recognized by Super Lawyers for excellence in their fields, insurance coverage and real estate, respectively.

Super Lawyers is a rating service of outstanding lawyers from more than 70 practice areas who have attained a high-degree of peer recognition and professional achievement.  Only 5% of attorneys in the Southwest receive this distinction. The selection process is comprised of independent research, peer nominations and peer evaluations.

Comitz | Beethe’s primary office is located in Scottsdale (Phoenix), Arizona and the firm also has satellite offices in Tucson, Arizona and Flagstaff, Arizona.

 

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What is an Independent Medical Exam?

An independent medical exam (“IME”) is an exam conducted by a doctor to verify whether you are truly disabled under your disability insurance policy’s terms.  These IMEs are rarely “independent”, and the doctors conducting them are almost always selected and paid by the insurers. In this post, we will explain what you can expect during an IME, and how you can protect yourself during the IME process.

What Can I Expect During an IME?

The IME doctor will likely begin by conducting an interview to learn about your medical history, the nature of your job, your symptoms, your treatment to date, and your daily activities.  During the interview, the doctor will be looking for signs that you are not telling the truth or that you are exaggerating your symptoms and limitations.  The doctor will pay attention to your demeanor, body language, and general appearance in order to assess your credibility.  The doctor will also compare your reported symptoms and limitations to your medical records, claim forms, and daily activities in an attempt to find inconsistencies.

Typically, the IME will largely consist of a physical examination, and the doctor may also require objective testing, such as x-rays, MRIs, or EMGs.  The doctor will often begin by conducting a general checkup, taking height/weight measurements, listening to your heart and lungs, testing your blood pressure, etc.  The doctor may then perform tests that focus on your disability and require you to provide subjective indications of pain and discomfort. He or she may ask you to bend, lift, or perform simple physical movements, depending on the nature and location of your condition.  Again, the doctor will be looking for inconsistencies or any signs that you might be exaggerating your symptoms.

After the IME, the doctor will complete a report that summarizes the findings of the exam.  The doctor will opine as to the extent of your disability, your ability to return to work, and recommended treatment or further testing.

How Can I Protect Myself in the IME Process?

As explained above, IMEs can be used as a tool for the insurance companies to deny or terminate disability benefits. Fortunately, there are ways you can protect yourself and ensure that you are treated fairly before, during, and after the IME.

Before the IME:

  • Review your policy. Most insurance policies do have a provision that allows the company to require you to submit to a physical exam.  However, these provisions are sometimes unclear as to the exact type examinations that are allowed.  Review the terms of your policy to make sure that your insurer can require you to undergo an IME.
  • Complete intake forms in advance. Your doctor will most likely ask you to complete intake forms, including questionnaires that outline your symptoms and medical history.  If you are nervous or hurried, you may forget to include important information.  Filling out the forms in advance allows you to answer each question carefully and accurately.

During the IME:

  • Bring a friend. If possible, bring a friend or family member to the IME. Not only can your friend provide moral support, but they will also serve as a witness to the exam.
  • Take notes. If possible, take notes during the IME to remember what testing was performed or what types of questions were asked. When you leave, write down your impressions and any issues you think you need to follow-up on.
  • Be cooperative and open.  Be patient and polite with the doctor.  Answer questions in a straight-forward and truthful manner, and if you do not understand something, let the doctor know. While you should be cooperative, this does not mean you need to do anything that causes you pain or injury. You know your body and limitations best, so if something the doctor asks you to do will cause you pain, let him or her know.
  • Discuss your symptoms fully and honestly. Do not minimize your symptoms and do not be afraid to complain.  It is important that your pain levels and other symptoms are documented as accurately and thoroughly as possible.
  • Connect your symptoms to your job duties. Make sure you discuss how all of your conditions impact your ability to practice safely and effectively. Give specific examples of how the conditions interfere with your practice (e.g., you cannot sit or stand for long periods without pain; you cannot manipulate dental instruments due to numbness in the fingers, etc.).

After the IME:

  • Get a copy of the report. After the exam, contact your insurer to ask for a copy of the IME report.  Review the report and compare it to your notes and recollection of the IME.  If anything needs to be clarified or there are any inconsistencies, contact your attorney and/or disability insurer as soon as possible.

If you have been scheduled for an IME, you may want to get an experienced disability insurance attorney involved.  An attorney can protect your rights during the IME process by finding out what the disability policy requires, limiting the test to certain parameters, studying the examiner’s credentials, recording the exam, accompanying you to the exam, and reviewing the final report for accuracy.

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Can You File a Disability Claim for Vision Problems?

It’s no secret that dentistry is hard work, requiring concentration, precision, visual acuity, depth perception, and quick reaction time if there is an emergency situation [1].  In prior posts, we have discussed how, as a result of these demands of the profession, musculoskeletal conditions are all too common in dentists, and often lead to dentists needing to file disability insurance claims. Similarly, a dentist who undergoes changes to his or her vision, whether via injury or disease, faces the very real possibility that he or she may need to step away from practicing dentistry early. In fact, one study showed that sight disorders were the second most common reason dentists asked for help (34.7% in females, 32% in males)[2], and the same study showed that sight disorders were recorded in 45.7% of the female dentists participating in the study and 48.5% of the male dentists, with eye injuries being the most common reported reason for seeking help.

Some eyesight injuries/impairments experienced by dentists may occur on the job, through physical hazards (radiation, artificial light) or chemical hazards (dental materials, including amalgam and dental cement particles, equipment, disinfectant, etc.).[3] Diseases of the eye are also not uncommon as one ages, and older dentists may find it increasingly challenging to effectively practice when faced with an eye disease, especially during procedures that require a significant degree of hand-eye coordination (e.g. root canals, crown procedures, etc.).

Some of the most common eye conditions in adults include age-related macular degeneration, cataracts, central retinal vein occlusion, retinopathy (due to diabetes), macular edema, glaucoma, and retinal tears and detachments. Many of these conditions can cause symptoms that can limit a dentist’s ability to practice safely and effectively (e.g. blurred vision, floaters, halos around lights, double vision, difficultly seeing in low or bright light, etc.), and over times some can even result in partial or total blindness. In addition, there are several lesser-known genetic eye conditions that can have equally devastating effects on a dentist’s ability to safely practice, including retinitis pigmentosa, choroideremia, Best disease, and cone rod dystrophy, among others.

Whether sight impairment and/or vision loss occurs through a common or rare disorder, vision problems are often slowly degenerative and progressive. In some instances, there may be ways to acceptably compensate for the vision impairment, whereas in other instances the impairment can be severe enough that it is obviously disabling. However, like other slowly progressive conditions, there is often a significant gray area between these two extremes that can be difficult to navigate if you do not have an understanding of how the disability claims process works. Dentists facing a progressive eye condition must carefully (and constantly) balance the need to keep their practice running, support their families, and continue the job they love against their duty to keep their patients safe and the risks of board complaints and/or malpractice lawsuits.

As a result, we’ve often seen dentists try to continue working even after a serious diagnosis by reducing their hours and/or the types of procedures they perform; however, doing so can hurt your chances to collect under a future disability claim, as this can undercut the severity of a claim and re-define the job duties, potentially making it much harder to establish total disability under the terms of your policy. Because of this, if you are a dentist with an eye condition that could potentially be disabling in the future, it is a good idea to have someone who is familiar with the claims process (like an experienced disability insurance attorney) evaluate your situation and start preparing a transition plan so that, if things progress to the point where you do have to file a claim, you are prepared.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described above and have yet to consult with a physician do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

 

References:

Mayo Clinic, www.mayoclinic.org
National Eye Institute, https://nei.nih.gov
U.S. National Library of Medicine, https://ghr.nlm.nih.gov
Retina International, http://www.retina-international.org
American Academy of Ophthalmology, https://www.aao.org
American Society of Retina Specialists, https://www.asrs.org

[1] Dhanya Muralidharan, Nusrath Fareed, & M. Shanthi, Musculoskeletal Disorders among Dental Practitioners: Does It Affect Practice?, Epidemiology Research International, Vol. 2013, Article ID 716897 (2013)

[2] Marin Vodanovic, Slavica Sovic, & Ivan Galic, Occupational Health Problems and Dentists in Croatia, Acta Stomatol Croat., 2016 Dec; 50(4): 310-320

[3] Id.

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“Do You Have a True ‘Own Occupation’ Policy?”

As a dentist, you probably have purchased at least one disability insurance policy, and you probably sought out “own occupation” coverage. However, in our experience, many dentists do not understand what their policy actually says or realize that there are several variations of “own occupation” policies. Additionally, many of the newer disability policies being sold to dentists have particular requirements and “rules” that must be followed in order to qualify for benefits.

Our latest article with Dentaltown Magazine discusses some of these pitfalls and explains why it is important to know what your policy says before filing a claim. Read the full article at Dentaltown today.

https://www.dentaltown.com/magazine/article/7481/do-you-have-a-true-own-occupation-policy

10 More Legal Mistakes Professionals Make When
Filing a Disability Claim (Mistake #1)

In an effort to provide professionals with more information about how the disability claims process works and identify some of the most common pitfalls for professionals filing disability claims, Comitz | Beethe attorneys Ed Comitz and Derek Funk have compiled an updated list of the 10 most common mistakes we are seeing physicians, dentists, and other professionals make when they file claims under the new post-2000 generation of disability policies (which are much more complex and stringent than the policies sold to professionals in the 1980s and 1990s).

In this post, we’ll be looking at the common mistake of not being actively engaged in the process of selecting your disability insurance coverage.

Mistake # 1: Blindly Relying on an Insurance Agent

Many professionals who are considering purchasing a disability insurance policy rely on an agent to find the right policy for them, often providing the agent with a vague, general objective like finding the “best” policy (or the “best” policy within the professional’s budget). In our experience, we’ve also found that it is common for professionals to go to an agent that a colleague recommended, and merely ask that agent to set them up with the “same” policy that their colleagues (e.g. the other doctors in their practice) have. Or, if the professional already has a policy, he or she may ask the agent to find them a policy that is the “same” as their existing policy.

This is problematic because there are no standard policies, and the differences between the multiple key provisions in policies are difficult to explain—even for an agent. Therefore, asking for the “same” coverage is often a request that is impossible for the agent to achieve. Additionally, while input from an agent can be helpful, insurance companies rarely provide agents with adequate training or information about a policy beyond what is necessary to sell it. As a result, agents are often unfamiliar with many of the complex terms in a policy, and the agent may not know how certain key provisions will play out during the claims process (which is understandable, as they typically just sell the policies and do not have legal experience filing claims or litigating these matters).

By design, insurance companies have now explicitly placed distance between themselves and their agents, for liability purposes. Most disability policies and policy applications now contain express language stating that agents cannot alter the terms of the policy, and disclaimers stating that the insurance company cannot be held liable for representations made by an agent. In the past, an agent’s representations could modify the policy under a legal principle called the “reasonable expectations doctrine,” so we would advice insureds to keep notes of any conversations with their agents (as well as any marketing materials). This legal doctrine is now largely obsolete given this new policy language limiting the insurance companies’ liability at the point of sale.

Action Step:  If you are considering purchasing a policy, do your own research and do not rely blindly on your agent to pick your policy for you. Do not accept coverage or pay premiums for a policy until you have thoroughly reviewed the policy.

To read the rest of the 10 most common mistakes, click here.

To learn more about some of the tactics insurers use to deny claims and other mistakes to avoid, click here.

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Doctor Money Matters Podcast
Q & A with Ed Comitz, Esq.
What Every Physician Should Know About Disability Claims

Ed Comitz recently sat down with Dr. Tarang Patel, host of the popular Doctor Money Matters Podcast, to talk through some of the most common questions physicians have about filing disability claims, such as:

  • What should a physician look for in a disability policy?
  • How hard it is for a physician to collect disability benefits?
  • Do I need a lawyer to file a disability claim?
  • What is the disability claims process like?
  • If I have an “own occupation” policy, can I work in a different occupation and still collect disability benefits?
  • What are the most common pitfalls that lead to physician’s claims being denied?

Click here to listen to Part 1 of the Podcast: https://www.doctormoneymatters.com/episode44/ and here to listen to Part 2: https://www.doctormoneymatters.com/episode45/.

Episodes can also be accessed on www.drmoneymatters.com, and via iTunes, Google Play, Stitcher and other podcast platforms along with Facebook and YouTube.

 

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10 More Legal Mistakes Professionals Make When
Filing a Claim for Disability (Mistake #2)

In an effort to provide professionals with more information about how the disability claims process works and identify some of the most common pitfalls for professionals filing disability claims, Comitz | Beethe attorneys Ed Comitz and Derek Funk have compiled an updated list of the 10 most common mistakes we are seeing physicians, dentists, and other professionals make when they file claims under the new post-2000 generation of disability policies (which are much more complex and stringent than the policies sold to professionals in the 1980s and 1990s).

In this post, we’ll be looking at the common mistake of failing to carefully review your policy application.

Mistake # 2: Failing to Carefully Review Policy Applications

In many jurisdictions, the law allows insurance companies to void policies if the application for the policy contains a “misrepresentation.” Most people believe a “misrepresentation” means something akin to fraud, but now even an honest mistake can void coverage in some instances, depending on the jurisdiction. Most policy applications contain unclear, compound questions or ask for detailed medical information that may be difficult to recall on the spot, off the top of your head. Additionally, most companies also require applicants to sign a disclaimer stating that the applicant has thoroughly reviewed the application and all statements made in the policy application are true. In some cases, an agent may complete the application for the applicant, or the applicant may provide the answers to the application questions via a phone interview, further increasing the risk that an incorrect statement, omission, or misrepresentation will be inadvertently made during the application process. Accordingly, applicants should be very careful when completing policy applications, as an incorrect response to even a seemingly innocuous or unimportant question can be construed as a misrepresentation that could result in the limitation or loss of coverage.

Action Step: Rather than completing the policy application in your agent’s office, take the application home with you so that you can carefully complete, review, and sign it on your own. Then keep a copy of your application in an organized file, so you have a record of the answers you provided.

To read the rest of the 10 most common mistakes, click here.

To learn more about some of the tactics insurers use to deny claims and other mistakes to avoid, click here.

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