Why Does My Insurer Want to
Conduct a Field Interview?
At some point after you’ve filed a disability insurance claim, your carrier may contact you to arrange a field interview. Also called a “field visit,” a field interview is when a disability insurer hires a representative to come meet with you face-to-face to talk about your benefit claim. Most times, the company will ask that you meet the field representative at your own home or office.
Your claims analyst will probably tell you that the field interview is just a way to get to know you better, or to help the company gain a better understanding of your disability claim. What the claims analyst won’t tell you are the real reasons why insurance companies put so much time and effort into planning in-person field interviews, such as:
- To take your picture so that a private investigator will recognize you during surveillance.
- To find out what your house and/or office looks like to further aid in surveillance.
- To look inside your house and see if you’ve been doing a lot of housework, paperwork, cooking for yourself, etc., all of which (according to the insurance company) can mean you’re able to work in your own occupation.
- To see if you look like you’re in pain, if you can sit down for a long period of time, or if you can walk without any gait abnormalities.
- To see if you look like you might have current monthly income from sources other than your occupation (i.e., if you have a nice car, a big house, a boat, etc.).
- To drop in and try to interview your spouse, former business partners, office manager, or neighbors.
- To try and get you to relax and open up, or to catch you off guard so that you give information the company can use against you.
In our next post, we’ll discuss what you can expect during the field interview itself.
Why Won’t My Doctor Help
With My Disability Insurance Claim?
We frequently discuss how important it is for your treating doctor to support your disability insurance claim. Oftentimes, though, doctors are reluctant to help with the process. Understanding why your provider is hesitant to get involved can better equip you to enlist his or her support.
In our experience, these are the most common reasons why treatment providers decline to assist with disability insurance claims:
They don’t have time. Doctors have extremely busy schedules. Often, they’re concerned that they simply don’t have enough time to properly complete all of the insurance company’s required forms or to answer questions from your claims adjuster.
They are worried about the insurance company harassing them. Many healthcare providers know how complex and combative disability insurance claims can be. Sometimes, providers don’t want to get involved with a claim at all, because they’ve heard of (or experienced) claims personnel harassing treating doctors. This can be a legitimate concern, as left unchecked, insurance companies will often bother treating doctors with repetitive requests for information, pushy phone calls, or by second-guessing the doctors’ treatment plan.
They are worried about doing something to hurt your claim. On the other hand, many providers aren’t familiar with the private disability insurance claims process at all. This sometimes makes providers hesitant to complete Attending Physician’s Statements or to discuss your claim with an adjuster for fear that they will inadvertently say something that prejudices you.
They don’t know the definition of disability in your policy. Not every treatment provider is familiar with the type of own-occupation policy that many physicians, dentists, and other professionals purchase. When some providers hear the word “disability,” they think of a state of total helplessness, or of the much more stringent Social Security definition of “disability.” If a provider doesn’t know that your policy deems you “disabled” if your condition prevents you from performing the duties of your own job, he or she might think you don’t qualify for disability benefits.
Continue reading “Why Won’t My Doctor Help
With My Disability Insurance Claim?”
Understanding Residual Disability Benefits: Are They Worth The Cost?
Part 3 – Current Monthly Income
In our previous posts, we identified the basic formula disability insurers use to calculate residual (partial) disability benefits and discussed variations in how disability insurers calculate Prior Monthly Income. Now, we will examine the other principal component in calculating a residual disability benefit: Current Monthly Income.
Current Monthly Income is the calculation of how much a doctor is earning now, versus how much he was earning prior to his disability. Although this sounds like a simple concept, calculating Current Monthly Income can be challenging in the healthcare industry. Many physicians and dentists own their own practices or are a partner in a practice group. Their income is not only based on their productivity, but also includes a passive component from the other business activities of the practice. For example, a dentist may employ one or more hygienists or associate dentists who generate additional revenue. When a doctor becomes disabled, the practice revenue may remain relatively constant as associates increase their production to account for the doctor’s reduced schedule.
Some insurers take advantage of this by calculating Current Monthly Income not on the doctor’s production, but rather on the practice’s revenue. This fails to take into account the true financial impact of a disability because, while revenue may remain high, expenses increase as associate doctors and hygienists work more (and earn more) to fill in for the disabled doctor.
Additionally, many doctors pay themselves based on a percentage of their own production, in addition to the income they earn as practice owners. When a doctor becomes partially disabled, his income from working in the practice will drop, even if the practice’s overall profitability does not. Depending on the language in a particular disability insurance policy, the policy may not take into account the drop in production, and the doctor may not be able to recover the full loss caused by his disability.
Electronic Medical Records: What You Don’t Tell Your Doctor Might Hurt Your Disability Claim
Over the last ten years, there has been an increasing movement away from paper records and toward Electronic Medical Records (EMR). This move has been accelerated by the federal government’s mandate that doctors who treat Medicare and Medicaid patients must have adopted and implemented EMR systems as of January 1, 2014.
There are many benefits to using EMR. They can facilitate patient care between referring doctors, improve data tracking over time, increase efficiency and reduce errors. However, EMR systems have drawbacks when they are used for purposes never intended, such as to document a disability claim.
Many EMR systems allow the doctor to input his findings for every major system in the human body, such as the cardiovascular, musculoskeletal, gastrointestinal, neurological and psychiatric systems. However, if the doctor does not put in something regarding one of the symptoms, the default setting on the EMR will report the system as being “within normal limits” or that the patient has “no complaints.” The concern with this from a disability perspective occurs when a patient sees his doctor for a condition unrelated to his disability.
For example, a patient with a history of degenerative disc disease could visit his doctor for an unrelated infection or illness. Since the doctor is conducting only a limited examination for purposes of treating the presenting illness, he may not input any information related to the patient’s disabling condition. The EMR will then generate an inaccurate record stating that the patient’s musculoskeletal system and neurological system are within normal limits.
Disability insurance carriers can then use these default settings to their own advantage to raise questions about the severity of the claimed disability, justify an independent medical examination or functional capacity evaluation, or support a claim termination. For patients who are receiving disability benefits, it is therefore important to know what their medical records look like and to effectively communicate with their physicians to ensure that their conditions and symptoms are accurately recorded on each visit.
Beware the “Offset”
Insureds may think that if their disability claim is approved and the insurer begins paying disability benefits, they have won the battle. In reality, however, even the insurer’s complete admission that the insured is disabled within the terms of the policy does not mean that the insurer will pay the full monthly benefit listed in the policy. Most of us think of disability insurance as providing a stream of income to replace lost salary, but few understand that these policies often contain language effectively cutting off other benefits to which the insured would otherwise be entitled.
Disability insurance policies, especially long-term disability policies, frequently contain “offset” provisions, which offset other benefits against the insurer’s monthly payments. Common offsets include benefits which the insured receives from Social Security disability or retirement, unemployment compensation, worker’s compensation, no-fault auto insurance, sick leave, severance pay, and others. The net effect of these offsets is that should the insured receive a benefit from another source, the disability insurance company will reduce its monthly payment by the same amount.
How Can I Keep My Disability Insurance Company From Contacting My Doctors Without My Consent?
In our recent post, “Should Disability Insurance Companies Be Deciding What Kind of Care You Receive?” we explained that insurance companies will often contact your treatment providers directly without your consent, ambushing them with medical studies and demanding answers to a plethora of questions about your medical treatment in an effort to undermine your disability claim. In many instances, insurance companies will refuse to produce the medical reports their in-house doctors wrote about you, but still expect full access to your treatment providers and their reports.
If this happens to you, you may (justifiably) feel like the insurance company is going behind your back and unfairly manipulating the disability claims process. Your treatment providers may become upset because the insurance company is harassing them to respond to detailed questions without adequate time to understand the questions and/or provide thorough answers. You may even notice your doctors acting differently towards you after speaking with the insurance company. For example, your doctor might begin to avoid you when you ask him or her to provide you with documentation to support your disability claim.
How can you protect your treatment providers from being ambushed by insurance companies and protect your claim from being manipulated?
How Functional Capacity Evaluations Impact
Your Disability Insurance Claim
Our last post discussed what to expect during a functional capacity evaluation (“FCE”), as well as the intended purpose of an FCE. Though FCEs can be a useful tool for measuring your abilities, FCEs do not always provide results that are truly indicative of your ability to do your job on a regular, consistent basis. Many courts have recognized the weaknesses and limitations of FCEs in the disability insurance claim context.
Weaknesses and Limitations of FCEs
There are approximately 10 different types of FCEs, each with its own program, measurement methods, and possible evaluative outcomes. Because FCEs can be influenced by many factors, such as physical ability, beliefs, and perceptions, FCEs need to “be interpreted within the subject’s broad personal and environmental context.”[1] Thus, the FCE “process and its administration are only as good as the examiner.”[2]
Disability insurers often stop paying benefits based on FCE results, even when you can’t actually meet the demands of your former job duties on a consistent basis. This is due to an inherent limitation of FCE testing: the FCE can only measure your capacity to do a certain task for a limited amount of time on a certain day. For instance, you may be able to push and pull ten pounds for a few minutes during the FCE, but that doesn’t mean you can do the same task all day, every day.
Another important limitation of FCE testing is how effort is measured. The FCE examiner normally monitors the subject’s heart rate to determine if he or she is putting forth full effort. If your heart rate isn’t high enough, the examiner will say you didn’t try your hardest, so you can probably do more than you demonstrated during the testing. However, there are factors that affect your effort level that can’t be measured by your heart rate alone. For example, heart rate monitoring doesn’t measure the impact of migraine headaches, kidney failure, or other non-exertional limitations (such as interference with attention and concentration due to pain and fatigue).
Continue reading “How Functional Capacity Evaluations Impact
Your Disability Insurance Claim”
What Is a Functional Capacity Evaluation?
After filing a disability insurance claim, your insurance company may ask you to undergo a Functional Capacity Evaluation, or FCE. The insurer tells you where and when to show up, but you likely have little idea what to expect when you arrive. What is an FCE, what is its purpose, and how will it affect your disability claim?
What Is an FCE?
FCEs are formal examinations performed by occupational therapists (OTs) or physical therapists (PTs), not physicians. The purpose of the FCE, according to your disability insurer, is to evaluate your ability to perform the substantial and material duties of your occupation.
What Can You Expect at the FCE?
FCEs usually last between four to six hours, but depending on the tests your insurer has requested, they could be longer, taking place over two consecutive days.
Continue reading “What Is a Functional Capacity Evaluation?”
What is an Incontestability Clause? An Arizona Case Study
What is an incontestability clause? An incontestability clause protects you against being denied coverage because of a preexisting condition.
This clause precludes insurance carriers from inquiring into the representations dentists, physicians, and other professionals made on the policy application if the two-year incontestable period has lapsed. In essence, the clause gives insurers a two-year time limit to review policy applications. If the insurance company makes no inquiry in those two years, they lose the ability to rescind the policy based on a preexisting condition.
For example in the case of Robison v. Brotherhood of R. R. Trainmen Ins. Dept.,[1] the plaintiff had been treated for tuberculosis prior to the effective date of the policy. Three years after obtaining the policy he became disabled from tuberculosis. When the insurance company tried to deny the insured’s claim, the Arizona Supreme Court ruled from its bench in Phoenix that the incontestable clause of the contract precluded the insurance company from inquiring about the insured’s health prior to the effective date of the policy.[2]
Second, this clause protects you against an insurance company’s attempt to deny a claim for disability insurance benefits based on a representation you made that is not material. For instance, when filling out the application for the insurance policy, you might write down the wrong year that you had some minor knee surgery. An insurance company cannot use such a miniscule and immaterial mistake to deny you coverage when your claim is for debilitating arthritis in your hands which doesn’t allow you to practice properly in your field of medicine.
Third, this clause protects an insured that is completely truthful when filling out the policy paperwork. In Paul Revere Life Ins. Co. v. Haas the court upheld a policy which limited “coverage to sicknesses that ‘first manifest’ themselves after the policy has been issued.”[3] This means that if you have a condition before the insurer issued the policy, but you don’t become aware of it until after the policy has become effective, the condition should be covered.
It is important to remember that and incontestable clause usually includes a caveat: it does not protect an insured that knowingly or fraudulently misrepresents information during the application process. The Haas court stated that the language of the incontestable clause “does not protect insureds who make fraudulent misrepresentations in their applications. Rather, the language is intended to protect those insureds who are unaware of their diseases.”[4] The insurance company in Haas (Paul Revere, a subsidiary of Unum) was allowed to deny coverage of the insured’s eye condition when the insured knew about and had been treated for the disease well before the start of the policy. The court believed that the legislature did not intend for the mandatory incontestable clause to be “an invitation for fraudulent applications for disability insurance.”[5] The preexisting eye condition was deemed to be a fraudulent misrepresentation, and the insurance company denied its coverage. We also discussed this topic in a previous post entitled “Medical History Misstatements On A Disability Insurance Application Can Void The Policy In The Future.”
The outcomes of the cases based on incontestable clauses show how important it is to be truthful throughout the insurance claim process. The more accurate you are about your health condition, the fewer coverage problems you may have down the road.
If you have questions about your policy’s incontestability provisions, an experienced Arizona disability insurance attorney can help talk you through how they work, and how that could impact your disability insurance claim.
[1] Robison v. Brotherhood of R. R. Trainmen Ins. Dept., 73 Ariz. 352, 241 P.2d 791 (1952), opinion modified on reh’g on other grounds, 74 Ariz. 44, 243 P.2d 472 (1952).
[2] Id.
[3] Paul Revere Life Ins. Co. v. Haas, 137 N.J. 190, 210, 644 A.2d 1098, 1108 (1994).
[4] Id.
Should Disability Insurance Companies Be Deciding What Kind of Care You Receive?
What role should your insurance company play in determining your treatment options? In our article, “Can Your Disability Insurer Dictate the Terms of Your Care?” by Ed Comitz and Michael Vincent, we discussed how, depending on the terms of your disability insurance policy, insurers can dictate what care you should receive, and whether you can be forced to undergo surgery in order to continue to receive policy benefits.
When prescribing you a specific treatment or medication, your doctor usually has very specific goals in mind. First, they want to medically treat you in the best way possible. They want to provide you with the best means for curing or coping with your situation after considering the totality of your circumstances and your recovery goals. Second, they want to make you feel better and help you recover from your ailments if possible.
For example, if surgery isn’t an option for your consistently high levels of pain, your doctor may prescribe strong medication to give you the relief you need. They may effectively manage the pain you struggle, but the side effects may impede you from returning to work.
Unlike doctors, insurance companies have one goal in mind: to get you off of their claims list and not pay monthly claim benefits. They want you treated in a way that returns you to work in the short run and may not be as concerned about the long term side effects or repercussions of alternative treatment options.
One way they accomplish this is by having their doctor contact your doctor to discuss treatment alternatives. Such alternative methods include using less effective medications that would allow you to return to work. A strategy they employ is to point your doctor to studies like those outlined in articles like “Disability experts question long-term opioid use,” or “Reed Group Releases New Opioid Treatment Guidance in Disability Guidelines.”
What many people don’t realize is that the Reed Group, the company who released the “updated expert guidelines,” is a subsidiary of Guardian Life Insurance Company, parent company of Berkshire Life. This company has a substantial incentive to downplay the safety and effectiveness of drugs, like opioids, that are able to manage acute pain, but render patients unable to return to work because of medication side effects. These companies want to point your doctors to these guidelines to influence their bottom line by getting you back to work quickly.
The problem with this tactic is that these blanket guidelines do not take into account your pain, your needs, or your situation. Yes, the alternative options may get you back to work, but in the long run you may experience repercussions. Letting claims consultants, who aren’t medical professionals, or the insurance company’s doctors determine your care and treatment is a conflict of interest for insurance companies and is not always in your best interests.
Ed Comitz Presenting Course “Disability Insurance: Will It Be There When You Need It?” at Western Regional Dental Convention on Friday April 4 and Saturday April 5, 2014
Attorney Ed Comitz will be giving a presentation called “Disability Insurance: Will It Be There When You Need It? Choosing Policies, Pursuing Benefits and Litigating Claims” on April 4th (Course Code F08) and April 5th (Course Code S06) at 8:30 a.m. at the Western Regional Dental Convention in Phoenix, Arizona. The course is worth three CE credits for dentists who attend. Registration information is available on the Western Regional Dental Convention’s website.
We are also an exhibitor at the dental convention. Please feel free to stop by our Booth 537 (directly across from the Internet Cafe) if you have questions about your disability insurance policy or claim.
How Long Do I Have to Formally File My Claim?
You have finally come to the realization that working through the pain and limitations of your disability is no longer in your best interests. Continuing to work is not an option for you, so you have decided to make a long term disability insurance claim. How long do you have to file your claim? Does it have to be on the day that you become disabled, or can it happen a couple months down the road? The answer to that question is: it depends.
Insurance companies will try and exploit every option available to deny a claim for disability insurance benefits. One method they utilize is to put strict requirements on how and when an insured must give notice to the company of their disability and what that notice must contain.
The first place to start looking to determine your insurance company’s requirements is the insurance policy itself. Look through the policy index or headings for a section similar to “Notice of Claim.” This section lets you know how much time is available to file a disability claim with the company. Continue reading “How Long Do I Have to Formally File My Claim?”
Unum Bases Its Decision to Deny Benefits on Surveillance of the Wrong Person
A recent disability insurance case from the Southern District of California, Barbour v. Unum Life Insurance Company of America, 803 F. Supp. 2d 1135 (S.D. Cal. 2011), illustrates yet another way in which insurers sometimes improperly use surveillance to deny or terminate policyholders’ claims. In this instance, Unum (parent company of Paul Revere, Provident, and UnumProvident) actually based its decision to deny a claimant benefits on surveillance footage of the wrong person.
Patricia Barbour was insured under a group disability insurance plan through her job as a school principal. Ms. Barbour filed a claim under her policy due to “severe right quadrant abdominal pain—inflammation small intestines,” for which she had undergone two hernia surgeries, with serious complications. She and her physician explained to Unum that her condition restricted her from driving, walking or standing, and sitting for extended periods of time, and that she was totally disabled from performing hers or any other occupation. Ms. Barbour also reported that she used a cane, and that she needed her mother’s help for her daily activities.
As typically occurs, Ms. Barbour’s claims consultant at Unum retained a private investigator to perform three days of surveillance on Ms. Barbour.
Continue reading “Unum Bases Its Decision to Deny Benefits on Surveillance of the Wrong Person”
Provident Loses the Battle Over Discovery of Employee Compensation and Bonus Information Tied to the Denial of Insurance Benefits.
In previous posts entitled “Why Is It So Hard To Collect On My Disability Insurance Policy?” and “Does Your Unum Claims Handler Have a Personal Financial Incentive to Deny or Terminate Your Disability Claim?”, we reviewed a leading reason behind insurance companies denying disability insurance claims: claims managers often receive incentives, including bonuses, depending on the amount of money they save the company. For the claims department, saving the company money is frequently achieved by denying the claims of existing customers who are receiving disability insurance benefits. This conflict of interest is a probable basis for denial or termination of many legitimate disability claims.
A recent discovery decision by the United States District Court, N.D. California in Welle v. Provident Life & Accident Ins. Co., 2013 WL 5663221 (N.D. Cal., Oct. 17, 2013) comes as a major win for those with legitimate disability claims. There, Doctor Dana Welle injured her left arm in a bike accident. After multiple surgeries, she was diagnosed with ulnar neuropathy and left medial epicondylitis. This condition gave her pain and weakness in her left arm that impacted her ability to safely care for her patients. After Provident Life Insurance (a Unum company) had paid almost three years of disability insurance benefits to Ms. Welle, the company denied her benefits.[1]
In her suit against Provident, which claimed bad faith denial of her benefits, Dr. Welle alleged that Provident’s “incentive structure was based on performance, and performance may be measured, in terms of resolution of claims, including her own.”[2] Dr. Welle requested Provident to produce “any and all documents that reflect, refer or relate to bonus awards, including but not limited to the performance rating and percent of bonus awarded” to claims managers and claim handlers.[3]
Provident objected to the request because, as they argued, it was overly broad and sought to obtain information that was private, proprietary and confidential. The Court overruled Provident’s objections and allowed the discovery. The Court reasoned that the information she sought in her requests “speaks to whether her claim was improperly denied and whether Provident encourages bad faith practices.”[4]
The Court further reasoned that Dr. Welle had shown compelling need for the documents that related to the bonuses of those involved in adjusting her disability insurance claim, and that the information was “highly relevant to her bad faith claim.”[5] The Court disagreed with Provident’s concern with the request being overly broad because it only requested bonus and performance related information of specific individuals. The Court also disagreed with Provident’s defense that discovering the information would breach the employees’ privacy rights, or that the information was proprietary and confidential, because Dr. Welle had already stipulated to a confidentiality agreement and protective order that covered the entire proceeding.[6]
Thus, the Court allowed discovery of the employees’ bonus and performance related compensation documents. Though this is not the end of Dr. Welle’s fight to receive her legitimate disability insurance benefits, it is a major step in helping her get the ammunition she needs to assure her of future benefits under the policy.
[1] Welle v. Provident Life & Accident Ins. Co., 2013 WL 5663221 (N.D. Cal., Oct. 17, 2013).
[2] Id.
[3] Id.
[4] Id.
[5] Id.
[6] Id.
Firm Named #1 Healthcare Law Firm
We are excited to announce that our firm has been named Arizona’s #1 Healthcare Law Firm by Ranking Arizona: The Best of Arizona Business.
Ranking Arizona publishes the results of an annual poll of the Arizona business community. Residents are asked to share their opinions of the best products, services and people in the state, including who they would recommend doing business with. We were selected as the state’s top healthcare law firm for its work representing physicians and dentists, including its handling of disability insurance claims for healthcare professionals.
The firm was also named as one of the top 5 Arizona law firms with 20 or fewer attorneys, the top 5 commercial litigation firms, and the top 10 real estate law firms.
Physicians and Dentists With Parkinson’s Disease:
The Condition, Its Occupational Impact and Disability
Introduction
Among the most devastating degenerative medical conditions is Parkinson’s disease, which currently affects 6.3 million people worldwide. While certain genetic conditions and environmental triggers may increase susceptibility to the disease, it is impossible to accurately predict who will develop it.
For healthcare professionals (physicians and dentists) diagnosed with Parkinson’s disease, the disease can be career-ending as symptoms become more severe. This post will provide a brief overview of Parkinson’s disease; explain the limitations the condition may create and how this could impact a professional career; and provide a solid base of information for anyone struggling with the prospect or process of filing a disability insurance claim.
Background
Every year, there are approximately 60,000 new diagnoses of Parkinson’s disease, a condition affecting the nervous system, motor control, and brain chemistry. Recent improvements in treatments, including exciting therapies involving “reprogramming” skin cells to behave like stem cells, act as small steps toward a solution, but there is currently no cure for Parkinson’s disease. Sufferers often go undiagnosed for many years, and because of the progressive nature of the illness, it can cause a slow deterioration in ability to function normally in day-to-day life.
Disease Progression
After the initial diagnosis and into early stages of Parkinson’s disease, symptoms may seem manageable and typically include fatigue, tremors, joint pain, and anxiousness.
As the disorder progresses, it is common to experience stiffness, lack of coordination, and slower movement. Everyday tasks such as getting dressed, shaving, writing, and brushing teeth can become strained, and there is a high susceptibility to falls and related injuries due to disturbed sense of balance.
Once Parkinson’s disease reaches advanced stages, affected individuals sometimes lose the ability to walk, speak, and properly care for themselves. Since Parkinson’s disease is a disorder of the nervous system, it can result in chemical changes within the brain, causing individuals to experience symptoms involving disruption of mental clarity, altered judgment, anxiety, or depression. In effort to control challenging symptoms, sufferers often go through the frustrating experience of experimenting with new medications, which can also produce unpleasant side effects.
Medical Professionals Diagnosed with Parkinson’s Disease
It is understandably difficult to grasp the frustrating new limitations that go along with Parkinson’s disease, as symptoms sometimes come and go, progressing gradually over time. Doctors who have been diagnosed with the illness may be tempted to continue practicing as usual, despite their worsening symptoms. Unfortunately, the reality is that the slightest side effect, such as tremor or delayed reaction time could potentially have life-altering consequences for practitioners or their patients. Should a doctor be sued for medical malpractice post-diagnosis, a jury could be convinced that the doctor should not have been practicing due to the nature of the illness, regardless of whether or not it was a factor in the incident. The dichotomy between lifelong work ethic and patient safety is what makes Parkinson’s disease so devastating to physicians and dentists – considering the amount of time, energy, and money invested into a professional career, there is a reasonable hesitancy to take a step back.
When to File a Disability Insurance Claim
Early Parkinson’s disease symptoms mimic other more common ailments, often causing the condition to go undiagnosed for lengthy periods of time; furthering the problem, no one test is able to confirm a diagnosis of Parkinson’s disease. Individuals undergoing the diagnosis process frequently experience a trial-and-error scenario, and symptom improvement with specific medications is often the litmus test for whether or not a person truly has the disease. These factors make it very difficult to determine when a disability insurance claim should be filed – when filed too soon, there may not be substantive proof of disability, but waiting too long could leave a practitioner exposed to liability.
A common mistake for sufferers of Parkinson’s disease is the attempt to modify work schedules and regular work duties with the progression of symptoms. Despite the fact that these measures are taken to avoid the risk of injury to the affected doctors or to their patients, the impact of this decision on future disability claims is substantial. A practitioner will typically perform fewer procedures, take on more management duties, and scale back hours over a period of time until working is no longer an option. The modification of one’s scope of practice and work hours can make it extraordinarily difficult, if not impossible, to collect future disability benefits, as insurance companies define a practitioner’s occupation (and ability to receive benefits) based on the work done at the time he or she becomes totally disabled. In short, this means that as one modifies his or her duties and hours, he or she is modifying both position and capability in the eyes of a disability insurance company to something less than that of a full time clinical practitioner. Keeping this in mind, it is best to explore the possibility of filing a total disability insurance claim as soon as possible after diagnosis, and it is prudent to speak with an attorney who is well-versed in filing disability claims.
Summary
Parkinson’s disease has had a personal impact on the lives of our staff, and we are no strangers to how difficult it can be to deal with long-term medical issues. Perhaps the most important step in accepting and understanding Parkinson’s disease is taking the time to get the help you need. Seek the support of family, friends, and professionals to help you cope with the changes ahead.
Additionally, understand that knowledge is power. Parkinson’s disease can have a major impact on finances, relationships, work, time, and various other aspects of daily life. Educating yourself about the future and what to expect, including when to file a disability insurance claim, will help you to feel more prepared and able to face challenges as they arise.
Understanding Residual Disability Benefits: Are They Worth The Cost? Part 2 – Prior Monthly Income
In the first post in this series, we identified the basic formula disability insurers use to calculate residual (partial) disability benefits. Now, we will examine how each of the components of that formula can change, depending on the insurer, and how those changes can affect the calculation of residual disability benefits, beginning with Prior Monthly Income (alternatively called Prior Earnings or Prior Net Monthly Income, depending on the insurer).
Prior Monthly Income, broadly speaking, is the baseline against which any loss of income is measured. If you are pursuing a residual disability claim, it is in your best interest to have the highest Prior Monthly Income possible. However, many doctors who file disability claims have conditions that are both chronic and progressive, like degenerative disc disease, which cause a slow, steady decline in productivity, and thus in earnings, for years before they ever make a claim for disability benefits. In addition to lowering the Prior Monthly Income, this can cause other problems with a disability claim, as discussed in our recent article on residual disability claims.
ABC News Investigates
CIGNA’s Disability Claims Handling Practices
UPDATE: Since this story was originally posted in 2008, the insurance regulators of Maine and Massachusetts initiated targeted market conduct examinations of CIGNA’s disability claims handling practices. The concerns raised by Maine and Massachusetts prompted the insurance commissioners of Connecticut and Pennsylvania to also open market conduct examinations and for the California Insurance Commissioner to reopen his previous examination of CIGNA. In 2013, the examinations resulted in fines against the CIGNA companies, corrective actions being required in its handling of disability claims, and for CIGNA to reevaluate certain claims that were denied or terminated. Information on the CIGNA Multi-State Regulatory Settlement Agreement can be found here.
ABC News/Good Morning America‘s investigation by Chris Cuomo into CIGNA disability claim denials has uncovered some disturbing stories. In the video above, claimants describe some of the hardships they have been forced to endure due to denials of their claims or unreasonable delays in having their claims paid.
One breast cancer survivor, who eventually was paid on her claim with the assistance of a disability insurance attorney, describes her two-year ordeal with CIGNA as a “daily, eight-hour job just to fulfill the information that CIGNA was requesting.” The tactic of wearing down a disabled claimant with repeated requests for documentation that has already been provided multiple times — thereby deliberately delaying payment of the claim — is called “slow walking” by some in the industry. While CIGNA denies engaging in this practice, many claimants who are already emotionally and physically vulnerable due to their disability will eventually quit pursuing benefits to which they are entitled in this battle of attrition that is widespread in the disability insurance industry. In this situation, it is often necessary for a claimant to retain the services of an attorney, not only to take on legal issues with the insurance company but also to shoulder the burden of the excessive and repetitive requests for documentation.
Other claimants in Chris Cuomo’s GMA piece describe (a) three years of fighting CIGNA for their benefits, all the while sinking deeply into debt and losing everything; (b) being caught between a rock and a hard place when told by an employer that he could not return to work due to his disability, but simultaneously having CIGNA deny disability benefits; (c) purchasing insurance to protect herself and her family, only to have her business destroyed, savings depleted and fighting to keep her family home when benefits were denied or delayed.
Another of the claimants profiled, Ursula Guidry, a young wife and mother with advanced breast cancer, initially had her benefits paid by CIGNA, but after awhile, they terminated her benefits and told her she could return to work full-time. Eventually CIGNA settled the claim with her. She passed away three months later. As her husband says, it is tragic that her last year on earth was spent being in a panic over financial issues and fighting an unethical insurance company instead of enjoying as much time as possible with her husband and children.
CIGNA did not respond to GMA re any of the specific claimants profiled, but their Chief Medical Officer stated they pay 90% of disability claims filed and that the majority of their customers are satisfied.
How to Tell if an IME Doctor is Really Independent
At some point during many disability insurance claims, the claimant is compelled to undergo a so-called Independent Medical Examination, or “IME”. The purpose of the IME is supposedly to have an uninterested, unbiased doctor examine you to verify whether your condition truly makes you totally disabled under your disability insurance policy’s terms. However, IMEs are often used as yet another tool for the insurance company to attempt to deny or terminate your claim for disability benefits.
Though IMEs are labeled “independent”, the doctors performing them are almost always selected and paid by the insurance company. Further, many of the IME providers are used over and over again by the same companies. IME doctors that depend on the insurance industry for their livelihood have a strong incentive to give the insurance companies results they desire–medical opinions that support the denial or termination of your disability claim.
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Can My Disability Insurance Company Contact My Employer?
We previously posted about the breadth of authorization forms that disability insurers request you sign at the beginning of your claim for disability insurance benefits. These forms allow your insurance company not only to obtain medical records and other relevant information, but also to contact your employer to discuss your specific job duties, among other things.
This can be unsettling as you may not want your employer to know about your medical condition, or you may fear what your employer might say that could jeopardize your disability claim. Unfortunately, there is little that you can do to stop the interview from occurring, but you can prepare yourself and your employer beforehand.
Most policies require that, in order to be considered “Totally Disabled,” you must be unable to perform the material and substantial duties of your occupation, and be under the regular care of a physician. Accordingly, your insurance company needs to ascertain your important occupational duties.
If you can still perform some of your important occupational duties, though not all of them, you will not be considered “Totally Disabled” under most policies. It is important, therefore, to anticipate that your insurer will contact your employer so that you can ensure that only accurate and relevant information is communicated.
There is a critical difference between important occupational duties, and those that are merely incidental. Duties that encompass only a small percentage of your time are incidental or peripheral duties and not part of your regular profession. It is therefore improper for your insurance company to consider these duties when determining your eligibility for disability benefits.
For example, a licensed dentist who works 90% of the time treating patients and 10% of the time on administrative duties is regularly engaged in chair dentistry for purposes of an own- occupation disability insurance claim. Administrative work such as overseeing office staff, paying bills or attending continuing education classes are merely incidental to his material and substantial duties as a full-time dentist.
By focusing on insignificant duties, and getting your employer to sign off on those duties as important parts of your regular occupation, your insurance company will have made it much more difficult for you to collect your rightful benefits. While this is an unscrupulous practice, it often occurs and produces an unfair result. Considering each and every incidental duty and allowing a finding that you are Totally Disabled only if you are unable to perform each and every one of those duties is a nitpicking approach that would equate Total Disability with utter helplessness. Obviously, that is not the type of coverage that you purchased, nor what had been marketed to you at the point of sale.
To ensure that your employer does not provide misinformation to your insurance company during the interview, here are some tips:
Prepare an Occupational Description: Prepare an occupational description listing your important duties and have your employer sign off on it. Then provide the occupational description to your insurance company at the beginning of your claim. By reviewing this document with your employer, it will be less likely that your insurance company will be able to focus on the irrelevant, incidental duties of your job.
Explain How Your Policy Works to Your Employer: Let your employer know that you have an occupation-specific policy that entitles you to benefits if you cannot perform the important duties of your job. Further explain that your occupational description is intended to outline your important duties, and other duties you may perform are merely incidental. This way, you are focusing your employer on what’s relevant and preparing him or her for the interview.
Being prepared and vigilant at the beginning of your claim increases the likelihood that you will be paid the disability insurance benefits that you deserve.
