Disability Insurance: Who Gets Denied?
Answer: Individuals with neck and back pain.
Musculoskeletal disorders make up 23 percent of new disability claims each year, says the Council for Disability Awareness, an insurance industry trade group. You can expect extra scrutiny if you file a claim for disability benefits, says Arizona disability insurance attorney Ed Comitz. The challenge with musculoskeletal claims is that there may be little objective evidence to verify the pain. Most insurers conduct surveillance on individuals with neck and back problems, attempting to portray them in the worst light notwithstanding the varying nature and severity of pain.
Claim Analytics, a provider of predictive modeling solutions to the insurance industry, published the results of its “2010 Long Term Disability Benchmarking Report.” The results show significantly varying results (a 22% difference) when it comes to dealing with claims,especially those based on back injuries. According to Claim Analytics, this reflects on the claim management practices employed by each carrier, and specifically how different carriers treat back pain.
The 10 Biggest Legal Mistakes Physicians Make
When Filing a Disability Claim (Mistake #1)
If you are a medical or dental professional and are thinking that you may need to file a claim under your disability policy, you may be wondering “Do I need to hire an attorney to file a disability claim?”
Given the voluminous, complex language of modern policies and the amount of money at stake, failing to consult with a lawyer is one of the biggest mistakes professionals make when filing a disability claim. An experienced disability attorney can explain the significance of key policy terms, and work with you to present the best claim possible while avoiding the pitfalls we have identified in our previous posts on this topic.
Ed Comitz’s article, “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), discusses ten of the most significant mistakes to avoid. The excerpt below explains the importance of consulting with an attorney before filing a long-term disability claim:
MISTAKE NO. 1: Failing to Consult With a Disability Insurance Lawyer
Physicians who are considering filing a claim for disability insurance benefits are advised to meet with an attorney experienced in the area before submitting a claim for payment. Disability provisions vary greatly in the language used, and coverage is often circumscribed and restricted by qualifying words and phrases. Accordingly, each insurance policy must be individually reviewed to determine whether a particular claim is covered and, if so, how that claim is best presented to ensure payment.
Action Step: Physicians should make a coordinated effort with the assistance of an attorney when interpreting their policy, presenting their claim, and providing subsequent information to their carrier.
Insurers have laid plenty of traps throughout the claims process. They will use private investigators, video surveillance, social media platforms, and similar tactics to harvest information and set up your claim for denial or termination. To learn more about these tactics and other mistakes to avoid, click here.
A Question of Ethics: When Is It Time to File a Disability Insurance Claim?
The physician considering a disability insurance claim is faced with a difficult decision: is it really time to look after her own health, or should she just keep working through the pain? An article by Richard Gunderman, a Professor at Indiana University’s School of Medicine, in American Medical News’ Ethics Forum argues that, while physicians should not be too preoccupied with their own health, they must also consider the safety of their patients: “As physicians, we bear a duty to recognize our own health-related limitations and take appropriate steps to safeguard those that depend on us.”
On the one hand, a physician’s disability or impairment may be so severe that she honestly doubts her ability to safely care for her patients. She may already be taking fewer shifts, seeking work accommodations, delegating tasks to her colleagues, and struggling to work around her disability. She may genuinely fear that when the pain is at its worst, her patients’ health is at risk.
On the other hand, the mere pursuit of a disability insurance claim can be grueling. Insurance carriers often resort to ruthless tactics to undermine a physician’s credibility and tear holes in legitimate evidence of disability just so they can deny the claim and save a dollar.
To complicate the matter, many physicians have loved ones who depend on their income. The potential for a prolonged disability insurance claim denial—and the resulting financial and emotional distress—can be frightening.
Gunderman suggests a solution: the physician should ask herself if she is still physically able to accomplish the selfless goals that drew her to the profession and commit herself completely to the patients and the community. “If we can position ourselves on the appropriate trajectory toward this higher end,” writes Gunderman, “the lesser goals, including the health of physicians, will find their proper orientation.”
And if the pain makes that impossible, it may be time to pursue a disability insurance claim. The decision may be evidence of deeper commitment to patient care: ”What might seem at first glance an admission of weakness,” says Gunderman, ”turns out to offer powerful testimony to the strength of a physician’s dedication to patients.”
The 10 Biggest Legal Mistakes Physicians Make When Filing a Disability Claim (Mistake #2)
Any medical or dental professional considering filing a claim or weighing long-term disability insurance policy options should be familiar with two key policy terms: “total disability” and “occupation.”
Misinterpreting the definitions of “total disability” and “occupation” and/or falling prey to other common pitfalls can lead to having your claim denied or your benefits terminated.
Ed Comitz’s article “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), details ten of the most significant mistakes to avoid. The excerpt below explains the importance of understanding these crucial definitions in your policy:
MISTAKE NO. 2: Misunderstanding the Definitions of “Disability” and “Occupation”
Because there is no such thing as a “standard” disability insurance policy, the definitions of “disability” can significantly vary. Most physicians purchase “own-occupation” policies, which provide compensation following a disability that prevents the insured from performing the particular duties of his or her occupation. Thus, the insured may be entitled to benefits even if he or she could in fact perform work of a different nature. The central issue in many cases is the definition of “total disability,” which could variously mean that the insured cannot perform “all” or “every” duty of his or her occupation, or the “substantial and material duties” of his or her occupation.
Similarly, the term “occupation” may be specifically defined in the policy (e.g., “invasive cardiologist”) or may refer to the insured’s occupation immediately prior to the time that disability benefits are sought. In the latter situation, if the physician reduces his or her hours in the months preceding claim filing, the insurer may consider his or her occupation to be part-time rather than full-time. Similarly, the term “occupation” may be comprised not only of the duties of a physician’s specialty, but also of significant travel time, teaching engagements, or other areas in which the physician spends time or draws revenue. For example, “occupation” may be defined as “internist/professor/business owner,” in which case the physician may not be “totally disabled” if he or she can still teach or perform management functions.
Action Step: Physicians should read and fully understand their policy terms before filing a claim for benefits.
Even if you read how these terms are defined in your own policy, you may not realize the significance of the definitions if you do not have a full understanding of the claims process and/or you have never seen any other policies for comparison as a frame of reference. Being familiar with the several variations of “own occupation” policies being sold by insurers can help you determine whether you have a true own occupation policy.
To learn more about some of the tactics insurers use to deny claims and other mistakes to avoid, click here.
The 10 Biggest Legal Mistakes Physicians Make
When Filing a Disability Claim (Mistake #3)
When you file a claim, at some point you will have phone calls with the insurance company regarding your claim. Oftentimes these conversations will be recorded and incorporated into the insurance company’s claim file, but you likely will not receive a copy of the recording unless your claim is denied and you end up filing a lawsuit challenging the denial. And even if the conversation is not recorded, it likely that, following your call, the analyst will be making a note in the claim file summarizing what was said in the conversation.
Because of this, it’s important that you do the same, to ensure there is a complete and accurate record of your interactions with the insurance company. Keeping records of what was said in these phone calls and evading other common pitfalls can help protect your claim from denial and your benefits from termination.
Ed Comitz’s article “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), details ten of the most significant mistakes to avoid. The excerpt below explains the importance of establishing a paper trail with your insurer:
MISTAKE NO. 3: Inadequate Documentation
When submitting a claim and speaking with their carrier, it is important that physicians take notes to assist them in remembering what was said in the event that their claim is denied. They should keep notes of all telephone conversations (including the date and time of the call, and what was said) and identify the person with whom they were speaking. Every conversation with the carrier should be confirmed in a letter sent by certified mail so that there are no misunderstandings. The “paper trail” may later be used as evidence to establish unreasonable treatment during the claim administration process.
Action Step: Starting with their first telephone call to their insurer, physicians should document in detail their conversations and meetings, and confirm everything in writing, sent by certified mail.
While you may have jotted down the occasional note when speaking with your disability insurer, you should now have a greater appreciation for the importance of establishing a record of what your insurer says and how they treat you. Detailed notes of conversations with your insurer can help shield valid claims from wrongful denial and even help prove bad faith conduct.
To learn more about some of the tactics insurers use to deny claims and other mistakes to avoid, click here.
Presenteeism: A Chronic Condition Among Doctors
A new article in the Journal of the American Medical Association suggests that presenteeism—showing up to work with an illness, impairment, or disability that limits productivity—has reached epidemic proportions among doctors. The study, which surveyed residents at multiple hospitals, found that three out of five had continued working while sick. At one hospital, 100% of residents had done so. Half the residents noted that they simply didn’t have the time to see a doctor.
Presenteeism imposes productivity costs on any business, but in the practice of medicine, these costs can include a noticeable decline in the quality of care patients receive. A physician suffering from an illness or disability—or distracted by severe physical pain—can make serious mistakes in judgment, which in turn can have life-threatening consequences for the patient.
Moreover, the presentee habit can become life-long. Later in their careers, physicians may not seek medical care for chronic conditions, injuries, or disabilities, even when they are legitimately unable to work. They may attempt to continue even the most physically and mentally demanding duties, aggravating the injury and putting patients at risk, even when they hold a disability insurance policy that could provide a safety net for their personal and professional finances.
Finally, a change in medical culture may be in order. Doctors should feel comfortable seeking the medical care they need, or even filing a disability insurance claim when appropriate. Dr. Vineet Arora, Associate Professor of Medicine at University of Chicago and one of the study’s authors, argues that “Hospitals need to build systems and create a workplace culture that enables all caregivers, not just residents, to feel comfortable calling in sick. Their colleagues and their patients will thank them.”
In Today’s Uncertain Financial Environment, How Difficult Will It Be for You to Collect on Your Disability Policy?
Attorney Ed Comitz’s article “In Today’s Uncertain Financial Environment, How Difficult Will It Be for You to Collect on Your Disability Policy?” was recently published in the July/August 2010 edition of The Journal of Medical Practice Management.
The 10 Biggest Legal Mistakes Physicians Make
When Filing a Disability Claim (Mistake #4)
As part of your long-term disability insurance claim, your insurer may require you to attend an independent medical examination (IME), ostensibly to assess the validity of your filing. Many physicians, dentists, and other professionals (understandably) feel anxious and concerned about attending an IME set up by their insurer.
Ed Comitz’s article “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), details ten of the most significant mistakes to avoid. The excerpt below notes policy language to watch for and covers several helpful steps to consider before, during, and after your IME:
MISTAKE NO. 4: Blindly Attending an Independent Medical Exam
After submitting their claim, physicians may be asked to submit to an “independent” medical examination by someone chosen and paid for by their insurer. They may also be asked to undergo exams by someone other than a physician. Before submitting to an independent medical exam or any other exam or evaluation, physicians must first ensure that their carrier has a right to conduct the exam per the policy language. For example, a neuropsychological exam is conducted over several days by a psychologist, not a physician, and insurers often use the subjective findings from such an exam to deny benefits. If the policy requires submitting only to “medical exams” or exams “conducted by a physician,” there is certainly an argument that a physician need not submit to neuropsychological testing. Further, physicians may wish to be accompanied by an attorney or other legal or medical representatives who can monitor the independent medical exam. Other considerations include receiving the examiner’s curriculum vitae in advance; limiting the scope of the exam to ensure that no diagnostic test that is painful, protracted, or intrusive will be performed; having the exam videotaped or audiotaped; and receiving a copy of all notes and materials generated.
Action Step: Because the “independent” medical exam is a tool used for denying benefits where possible, physicians should work with an attorney to ensure that their rights are protected during this process.
Reviewing your policy’s requirements and preparing to attend an independent medical examination can make the process less stressful and protect valid claims from wrongful denial.
An IME is often just one part of your insurer’s broader investigation of your claim. To learn more about other common pitfalls to avoid, click here.
The 10 Biggest Legal Mistakes Physicians Make
When Filing a Disability Claim (Mistake #5)
Many disability policies now contain provisions that limit coverage for mental conditions. However, each policy also contains specific definition of the types of conditions that are limited and/or excluded, and these definitions can vary greatly from policy to policy.
Ed Comitz’s article “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), details ten of the most significant mistakes to avoid. The excerpt below explains why you should read your policy carefully, to ensure that limitation provisions in your policy are correctly applied to your particular situation:
MISTAKE NO. 5: Believing All Mental Conditions Are Excluded or Subject to Limitations
Most disability insurance contracts differentiate between mental and physical disabilities. Most recent policies cut off benefits for psychiatric conditions after two or three years. Insureds often blindly accept their carrier’s decision to deny or limit benefits based on these conditions without considering numerous relevant factors, including whether there are any physical aspects to the mental condition, whether the mental condition has a biological/organic cause, or whether another, covered condition was the legal cause of the disability. Without exploring these issues in detail, insureds often blindly accept that certain conditions are limited or excluded from coverage when in fact they are not.
Action Step: Physicians should understand their policy’s mental conditions limitation and work with counsel on submitting their claim in such a manner as to ensure payment of benefits.
If you have submitted, or are considering submitting a disability claim, based on a mental illness, be sure to carefully review your policy’s language and do not simply assume that all mental conditions are excluded. And if your insurance company relies on one of these limitation provisions to deny your claim or limit your benefit period, you should consult with a disability insurance attorney and assess whether the insurance company’s decision is proper under the terms of your policy.
To learn more about the tactics insurers use to deny claims and other mistakes to avoid, click here.
The 10 Biggest Legal Mistakes Physicians Make When Filing a Disability Claim (Mistake #6)
If you are a physician, dentist, or other professional facing a disabling condition, you may be wondering when to tell your doctor that you’re thinking you may need to file a disability claim, and how to communicate it best. How and when you approach your doctor can have a significant impact on your claim, particularly if you have a slowly progressive condition, like an essential tremor or degenerative disc disease.
Ed Comitz’s article “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), details ten of the most significant mistakes to avoid. The excerpt below discusses some important considerations to keep in mind when interacting with your doctors:
MISTAKE NO. 6: Engaging in Inadequate Communication with Treating Physician
Physicians should not discuss their claim or that they are considering filing for disability insurance benefit with their treatment provider until after they have had several visits. Physicians are often reluctant to support claims for benefits if they question the motivations behind the claims. A physician who has treated, without success, the physician making the claim will likely be more willing to cooperate. It is also important that the physician making the claim communicate his or her symptoms and limitations to the treating physician in an organized and detailed manner so that all relevant information is recorded in the medical records, which the insurer will ultimately request. When finally speaking to the treating physician about the claim, the physician should ensure that the treating physician understands the definition of “disability” under the insurance policy, so that he or she can accurately opine as to the inability of the physicians making the claim to work.
Action Step: Physicians should fully discuss their condition with their treating physician to ensure supportive medical records and, after several appointments, work with him or her on submitting the claim for “disability” as defined in the policy.
Your doctor plays significant role in documenting the health information your insurer will eventually obtain and review when investigating your claim. With that in mind, it is important to understand the relevant definitions in your disability policy, consider the nature of your symptoms and limitations, and carefully consider when to approach your treating physicians about your disability claim.
To learn more about the tactics insurers use to deny claims and other mistakes to avoid, click here.
The 10 Biggest Legal Mistakes Physicians Make When Filing a Disability Claim (Mistake #7)
If you have never filed a long-term disability claim, you may not have given much thought to how to quantify job duties, but if you end up needing to file a claim, this is one of the first questions you’ll be asked on the disability claim forms. It is very important to be careful when filling out these portions of the claim forms, to prevent your insurer from taking advantage of imprecise responses and/or taking your responses out of context in order to deny or narrow the scope of your benefits.
Ed Comitz’s article “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), details ten of the most significant mistakes to avoid. The excerpt below discusses some considerations to keep in mind when completing this section of your initial claim form:
MISTAKE NO. 7: Quantifying Time
Physicians should be wary of insurance companies asking them to compartmentalize in percentages what activities they were engaged in pre- and post-disability. To the extent that there is any crossover, companies will often deny benefits or provide benefits for merely a residual disability. It is important that physicians broadly describe their important duties—rather than their incidental duties—so that the insurer has a clear understanding of the thrust of their occupation. For example, in response to a question about principal duties and the percentage of time spent on each duty, an anesthesiologist may be better off stating “100% surgical anesthesia” rather than compartmentalizing each and every incidental task (e.g., patient intake, supervising nurses during surgery, postoperative visits) into discrete percentages. The reason is the insurer may erroneously consider an incidental task a “principal duty,” and therefore downgrade the amount of benefits. For example, where a physician has duties as a businessman (e.g., supervising staff, overseeing payroll), the insurer may argue that the disabled physician can still manage his or her practice and is therefore only partially disabled.
Action Step: Physicians should not quantify their time until after they fully understand the definitions of “principal duties,” “disability,” and “occupation” under their policy.
To learn more about some of the tactics insurers use to deny claims and other mistakes to avoid, click here.
The 10 Biggest Legal Mistakes Physicians Make When Filing a Disability Claim (Mistake #8)
After submitting a claim for long-term disability benefits, it is important to keep in mind that your insurer will almost certainly conduct surveillance at some point (and many insurers use surveillance throughout the entire claim). Traditionally, insurers used private investigators and interviewers to conduct surveillance, but ever-advancing technology is providing insurers with even more tools to conduct surveillance, such as social media, online public record searches, and potentially GPS tracking, drones, stingrays, and other electronic methods of tracing your activities more closely and accurately than ever before (depending on whether lawmakers act to curb abuse of these new, emerging technologies).
Ed Comitz’s article “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), details ten of the most significant mistakes to avoid. The excerpt below explains why you should be aware of the potential for surveillance:
MISTAKE NO. 8: Ignoring the Possibility of Surveillance
Insurers are likely to videotape or photograph physicians who have filed for disability insurance benefits. Physicians who engage in any activities that they claimed they could not perform and are caught on tape are likely to have their benefits denied and the contract could be terminated.
Action Step: Physicians should not compromise their policy benefits by submitting a fictitious claim.
If you are considering submitting a long-term disability claim, remember that modern technology enables insurers to harvest information about you from the internet, and remain wary of suspicious situations that may be the insurance company’s investigators using pretexting to obtain information about you (for example, “friend” requests from individuals that you do not personally know may be efforts to gain access to your social media accounts).
Excessive, unnecessary surveillance can rise to the level of bad faith, and too often these types of methods are misused to manufacture “evidence” that insurers take out of context to terminate (and/or delay) benefit payments. If you think your insurer may be misusing surveillance in your claim, you should talk to an experienced disability insurance attorney and he or she can evaluate whether or not the scope of the insurer’s investigation is appropriate.
To learn more about some of the tactics insurers use to deny claims and other mistakes to avoid, click here.
The 10 Biggest Legal Mistakes Physicians Make When Filing a Disability Claim (Mistake #9)
Many insurance companies tell physicians, dentist and other professionals who have filed a long-term disability claim that their claims will not be approved unless they can produce objective evidence of their disabling condition. While some policies do contain express provisions limiting coverage for subjectively diagnosed conditions, many policies do not. In fact, your policy may be less exacting and require only verifiable evidence of disability. Under such a policy, you may still be able to collect if you can show that the cumulative effect of your symptoms and limitations are disabling.
Ed Comitz’s article “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), details ten of the most significant mistakes to avoid. The excerpt below explains why verifiable evidence of disability is important, even for subjective conditions:
MISTAKE NO. 9: Blindly Accepting that Subjectively Diagnosed Conditions Are Not Covered
Disability insurers often deny benefits by insisting that the insured’s subjective symptoms do not provide objective, verifiable evidence of disability. In many cases, there is no provision or contractual requirement mandating that the insured submit objective evidence of disability. Therefore, from the insured’s perspective, these insurance companies are merely trying to save money by generously interpreting policy language in favor of a claim termination. Notwithstanding the subjective nature of a particular condition, the insured may be able to secure benefits with ample evidence bearing on the extent and severity of his or her limitations, which is far more important than providing a definitive diagnosis.
Action Step: The severity and extent of the limitations are more important than an objectively verifiable diagnosis and must be fully communicated to a physician’s insurer.
If you are a physician or dentist suffering from a subjectively diagnosed condition, it is important to present your conditions and limitations in a precise and detailed fashion from the outset of your claim. At a minimum, this requires a supportive treating doctor who is willing to take the time to thoroughly document the extent and severity of your symptoms in your medical records.
To learn more about some of the tactics insurers use to deny claims and other mistakes to avoid, click here.
The 10 Biggest Legal Mistakes Physicians Make When Filing a Disability Claim (Mistake #10)
Many physicians, dentists and other professionals who purchase disability insurance do not pay much attention to the policy and related documents once their application has been submitted and approved. Because of this, many of the professionals we consult with cannot find their policies when it comes time to file a claim, and many professionals are surprised to learn what their policies say, because they didn’t read them carefully when they first received them.
Ed Comitz’s article “The 10 Biggest Legal Mistakes Physicians Make When Filing a Claim for Disability,” published by SEAK, Inc. (2005), details ten of the most significant mistakes to avoid. The excerpt below explains why you should keep copies of all of your insurance documents:
MISTAKE NO. 10: Tossing Out Application, Policy, and Claims Documents
From the time of application forward, physicians should keep copies of everything (including notes from meeting with the insurer’s sale representative or agent, the policy application, and the policy itself). If the sales representative provided a letter or verbal representation that the physician jotted down, those notes can go a long way if the insurer says that the policy says something different. Similarly, information that the physician provided on the application may have a bearing on his or her reasonable expectations at the time of purchase.
Action Step: Physicians should keep all of the disability insurance papers and notes in an organized file.
If you end up losing your policy, you do have a right to request a duplicate copy from your insurer. However, it can take several weeks for insurers to process these requests, and your insurer may also use the request as an opportunity to interview you before you know what your policy says, and before you have a chance to speak with a disability insurance attorney about your claim.
Depending on your condition and the progression of your symptoms, if you don’t keep a copy of your policy, you may also be forced to decide whether you are going to file a claim without a complete understanding of what your policy says. This is not a position you want to be in, and it is therefore best to keep all of your policy documents so that you have them on hand if you need them.
To learn more about some of the tactics insurers use to deny claims and other mistakes to avoid, click here.
Northwestern Mutual Offers Insight Into How Disability Insurers Interpret and Apply “Own Occupation Coverage”
Northwestern Mutual Life Insurance—a major provider of disability income insurance for physicians and dentists—has just launched a new website, the “Disability Income Insurance Knowledge Center,” which it claims will help policyholders understand the terms of their “own occupation” disability insurance coverage.
“Own occupation” policies are often marketed by disability insurers as allowing physicians and dentists to receive their full disability insurance benefit, while at the same time working in another occupation, as long as they can no longer practice medicine or dentistry. Some disability insurance policies further specify that the insured’s specialty will be considered his “occupation” for purposes of “own occupation” coverage. Under these disability policies, as they are frequently marketed, an insured could receive his full benefit, even if he is still working as a physician or dentist, as long as he is disabled from his former specialty.
As an example, a neurosurgeon who develops a hand tremor may still be a capable doctor, but he can no longer perform surgery. Since he can no longer perform the principal medical duty of neurosurgery (i.e., surgery), it would be logical to conclude that he would be disabled from his occupation as a neurosurgeon. However, Northwestern’s new website has an interactive “Fact or Fiction” quiz in which it offers its interpretation as to how these “own occupation” provisions should be interpreted. Northwestern’s conclusions are gross oversimplifications that fail to consider the nuances of a disability claim, and ignore differences in policy language and the manner in which the policies have been interpreted under Arizona law. These oversimplifications appear designed to dissuade individuals with legitimate disability claims from pursuing their remedies. Nevertheless, they offer a glimpse into how disability insurers often view an insured’s occupational duties. Some samples from the “quiz” include the following statements:
Statement: If I could not perform my principal medical duty, the one that’s my “bread and butter,” I’d be considered totally disabled under an “own occ” policy.
Northwestern Mutual: FICTION. “To be totally disabled under traditional ‘own occ’ disability income insurance definitions, you would have to be unable to do ALL of your principal duties.”
Depending on the terms of his “own occupation” policy, an Arizona physician or dentist may be totally disabled if he cannot perform any substantial part of his ordinary duties in his usual and customary manner. In one major case, an invasive cardiologist was no longer able to perform invasive procedures—a substantial part of her original duties—but continued work in non-invasive cardiology and geriatrics. The jury found her totally disabled under her “own occupation” policy and held that her insurer had denied her disability insurance claim in bad faith. It then awarded her $84.5 million.
This statement also reflects an important issue in interpreting these policies – while countless words and phrases are defined, the phrase “principal duties” is generally not defined. Taking advantage of this fact, insurers often attempt to transmute incidental duties, such as staff oversight or pre- and post-operative patient consultation, into principal duties, without any justification for doing so. If insurers were permitted to do this, as Northwestern suggests, it would render “own occupation” coverage illusory since, absent a catastrophic injury, the insurer would always be able to find that the insured could perform some duty of his prior occupation. Fortunately, Arizona courts do not permit insurers to classify all duties as “principal duties.” As one Arizona court noted “[f]ew specialty occupations could survive such piecemeal scrutiny. If separated into an hour-by-hour analysis, only asking the question whether these tasks are also performed in a more general setting, specialists who choose to continue to work in a more general practice after becoming disabled from their specialty could never qualify for total disability benefits, although the policy specifically allows for this.” Continue reading “Northwestern Mutual Offers Insight Into How Disability Insurers Interpret and Apply “Own Occupation Coverage””
Insurers Use High-Pressure “Return to Work” Programs to Terminate Disability Insurance Benefits
A personal return to work plan can be useful and empowering when it is the product of careful consideration between a disability insurance claimant, his doctor, and his attorney.
In the hands of a disability insurer, however, a return to work strategy is simply a means of beefing up the bottom line by pushing a claimant to give up his benefits and return to work before it’s safe.
To compound the problem, insurers increasingly market their return-to-work pressure methods to employers who seek to minimize disability-related absenteeism, dubbing the relationship a “strategic partnership.” Prudential, a major provider of disability insurance policies, offered its approach at the annual Disability Management Employer Coalition (DMEC) Conference in San Diego. In describing its methods, Prudential argued that “[s]ome disability absences are driven by subjective feelings about work,” a problem best solved by “an environment that breeds commitment.” Unum, one of the nation’s largest disability insurance providers, has given similar presentations, including one on strategies for managing employees’ chronic pain conditions—callously titled “A Pain in the Workplace.”
The unfortunate outcome is that the claimant faces pressure from both her employer and her insurer to return to work prematurely, often on a “trial” basis—a decision that can lead to forfeiture of benefits, aggravation of medical problems, and other complications.
Consult your doctor and a reliable, knowledgeable attorney before you consider returning to work, even for a “trial” period. The effect on your benefits and health could be profound.
Look Who’s Lurking Around Your Facebook Page: Your Insurance Company!
The detailed information many people reveal about themselves on popular social networking sites such as Facebook, Twitter, and MySpace has caught the attention of the insurance companies. Insureds with disability claims should be alert to their insurance company potentially using this investigation/surveillance tool and should think twice before posting photos and information about their daily lives that could be misconstrued and used against them. Marilyn Lewis has written an interesting article on Insure.com about the future of insurance companies investigating their insureds online not only in order to determine rates for home, auto and life insurance, but to conduct surveillance on insureds with claims.
Disabled Doctor Wins Fight Against Unum Life
On June 11, 2010, Salient News reported on a disabled doctor who prevailed against Unum in court to receive disability insurance benefits to which he was entitled. The attorney for the doctor discussed the tactics used by the insurance company:
Unum has shown a long-standing pattern of denying occupation specific policies focusing on denying high earning professionals such as doctors, lawyers, chiropractors and the like. Unum uses its own appeal process to unjustly prejudice and deny valid and deserving claims.
Unum Profits While Ailing Workers “Gut it Out”
In an interview with Andrew Frey of Bloomberg Businessweek, Unum Group CEO Thomas Watjen said that the economic slump has resulted in fewer disability claims being filed, with workers suffering from lower back pain, nervous conditions and other “more discretionary” conditions more likely to “gut it out” than they would in better economic times.
You can’t make a windfall on these products. It’s not like you can go on claim and make an enormous amount of money.
While workers are gutting it out, Unum has reported five straight quarterly profit increases.
