Does Arizona Require My Disability Insurer to Respond to My Letters?
Disability insurers often utilize the tactic of sending request after request for additional information for you to respond to. But what happens if you have a question for your insurer? Does your insurer have to respond?
Although it may feel that you are simply sending a letter into the void, Arizona actually requires your insurance company to respond to you. Specifically, your insurer must acknowledge receipt of correspondence within ten days, unless payment is made within this period of time. See Ariz. Admin. Code § 20-6-801(E)(1).
Further, in Arizona, “an appropriate reply [must] be made within 10 working days on all other pertinent communications from a claimant which reasonable suggest that a response is expected.” Ariz. Admin. Code § 20-6-801(E)(3).
In our experience, insurance companies often drag their feet in making a claim decision, especially in high dollar claims filed by dentists, physicians and other professionals. One way to ensure your case doesn’t end up on the back burner is to continue to engage with your insurance company.
If you have communicated with your insurance company, but aren’t receiving timely replies, please feel free to reach out to one of our attorneys directly.
Atrial Fibrillation
Atrial fibrillation (also known as A-fib or AF) is an irregular, and often rapid, heart rate. When atrial fibrillation occurs, the heart’s two upper chambers beat irregularly, out of sync with the two lower chambers. Some people will have atrial fibrillation between periods of normal heartbeats (also called intermittent or paroxysmal AF) while others have persistent AF.
Atrial fibrillation increases the risk of stroke five fold (causing about 1 in 7 strokes), and these strokes are often more severe than strokes with other underlying causes.
Symptoms
- Palpitations
- Fainting
- Dizziness
- Fatigue
- Weakness
- Shortness of breath
- Angina pectoris (pain caused by reduced blood supply to the heart muscle)
Causes/Risk Factors
- Age (more common over age 50)
- Gender (more common in men)
- Race (more common in Caucasians)
- Other heart diseases and conditions
- Hypertension
- Diabetes
- Thyrotoxicosis (an excess of thyroid hormones)
- Obesity
- Chronic kidney disease
- Moderate to heavy alcohol use
- Smoking
- Sleep apnea
Studies have also suggested that stress and mental health issues may cause atrial fibrillation symptoms to worsen.
Diagnosis
Atrial fibrillation is typically confirmed with the following:
- Physical examination
- Electrocardiogram (ECG)
- Echocardiogram
- Blood tests
- Stress test
- Chest X-ray
Treatment
The goal of treatment is to reset the rhythm and control the rate of the heart and to prevent clots in order to decrease the risk of a stroke. To that end, treatments include:
- Electrical cardioversion
- Medicines to control the heart’s rhythm and rate
- Blood-thinning medications
- Surgery
- Medicine and lifestyle changes to manage risk factors (see above)
Given the increased and serious risk of stroke, your doctor may advise you to limit stress, especially since intense stress may cause heart rhythm problems. Stressors can come from a variety of different sources, including working as a dentist or physician. If you have been diagnosed with atrial fibrillation and feel that you may need to file a disability insurance claim, please feel free to contact one of our attorneys directly.
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 doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms
Sources:
CDC
Mayo Clinic
John Hopkins
Latest Unum Lawsuit – January 2022 Update
As we’ve discussed before, Unum is one of the insurance companies that gets sued the most for mishandling disability insurance cases. Unum was also the target of a multi-state conduct exam in 2004. This exam identified several inappropriate claims handling practices, including excessive reliance on in-house medical staff, unfair evaluation of attending medical examiner notes, failure to evaluate the totality of the claimant’s medical condition and placing an inappropriate burden on claimants to justify their eligibility for benefits.
Despite an estimated settlement cost to Unum of around $120 million, we still see them implementing these claims handling practices in an effort to deny legitimate claims. One such example is the recent case of Gary v. Unum,[1] discussed below.
Prior to her disability, Alison Gary was an associate attorney at a law firm. Gary was diagnosed with Ehlers-Danlos syndrome (EDS) Type III, an incurable connective tissue disorder. Common symptoms include joint hypermobility and chronic musculoskeletal pain.[2] In addition, she was subsequently diagnosed with cervicomedullary syndrome, a condition where pressure on the brain stem causes neurological problems. In Gary’s case, she suffered cognitive problems, weakness, impaired coordination, bladder problems, numbness, tingling, and other sensory disturbances. After this diagnosis, her doctor ordered her to stop working immediately (both due to cognitive and physical impairments), which Gary did on December 1, 2013.
Given her symptoms, including her severe neck pain, headaches, cognitive changes, word-finding issues, weakness, sensory loss, and imbalance (among others), a neurosurgeon recommended surgery. The doctor stressed that the surgery would “not offer a panacea for all her problems” and would only take care of some of her issues. On October 6, 2014, Gary underwent suboccipital decompression, reduction, and occipitoaxial fusion-stabilization surgery.
Prior to surgery, the doctor estimated that results may take 6 months. Despite the fact that Gary did not fully recover in 6 months, Unum denied benefits after April 6, 2015. The Court found that Unum abused its discretion because there was “over-whelming post-surgical medical evidence that anticipated a longer recovery.”
We’ve often seen Unum try to force claimants back to work after surgery—despite limited or insubstantial recovery, based solely on recovery predictions (often made by the insurance company’s own doctors). In reviewing Unum’s conduct, the Court noted that Unum did not conduct an Independent Medical Examination or hire and EDS specialist; instead, Unum relied on hired consultants to conduct a paper review of Gary’s records. These consultants specialized in orthopedic surgery, family medicine and psychology.
Unum also cherry-picked from the medical evidence. For example, they ignored statements in medical records that indicated that the surgery would not be a “panacea”. While there were statements in her records that some of Gary’s conditions had improved after surgery, there were also numerous statements in the records that explicitly explained that Plaintiff was not yet able to return to her employment as an attorney.
When this case was initially heard before the District Court of Oregon, the Court actually found in favor of Unum as it applied a moderate level of skepticism to its abuse of discretion review of Unum’s actions. However, after being appealed, the Ninth Circuit Court of Appeals remanded the case, stating that the district court should apply a heightened level of skepticism in determining whether Unum abused its discretion.[3] Under this heightened level of skepticism, the Court found in favor of Gary.
This case highlights that Unum is one of the most aggressive companies in the industry that appears to be reverting back to their old ways. Other disability insurance companies may follow suit and begin implementing similar practices into 2022, as in the past we’ve seen Unum act as a bellwether of sorts for the industry.
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 insurer is using any of the tactics above to evaluate your claim, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.
[1] Gary v. Unum Life. Ins. Co., No. 3:17-cv-01414-HZ, 2021 WL 5625547 (D. Or. Nov. 29, 2021)
[2] NIH Genetic and Rare Disease Information Center, Hypermobile Ehlers-Danlos syndrome, https://rarediseases.info.nih.gov/diseases/2081/hypermobile-ehlers-danlos-syndrome
[3] Gary v. Unum Life Ins. Co. of Am., 831 Fed.Appx. 812, 814 (9th Cir. 2020)
Disability Insurance Claims: Top 5 Trends of 2021 and Outlook for 2022
As leaders in the professional disability insurance industry, our disability insurance attorneys are committed to keeping dentists, physicians, other attorneys and executives apprised of industry, regulatory, and legislative changes that may impact their ability to collect benefits under “own occupation” disability insurance policies.
In this post, we will be sharing some of the disability claims management trends we have noticed in 2021, discussing some recent surveys of private disability insurers that may explain these trends, and providing our disability insurance outlook for 2022.
For a broader discussion of the history of the disability industry and a discussion of common bad faith tactics and new policy provisions to be aware of, please visit our homepage.
Disability Industry Trends of 2021
Over the course of 2021, there has been a noticeable uptick in claims relating to a variety of factors, including COVID-19’s impact on healthcare practices, sales and operations (particularly dental practices); an uncertain economy with higher unemployment and lower interest rates; and a significant increase in physicians and dentists filing disability insurance claims based on mental/nervous conditions.
Additionally, from the disability insurance industry’s perspective, there are fewer individuals purchasing own-occupation policies, and policyholders are often selecting lower monthly indemnities if they do purchase policies.
The professional disability insurance industry is also facing additional sales obstacles, including aging producers (with younger producers focusing more on asset management), an aging distribution model, nonengaged advisors, and lack of knowledge and training for agents on newer policies.
Disability Claim Trends of 2021
Professionals, such as physicians, dentists, attorneys and executives, have historically pushed through disabling conditions longer than they should—a phenomenon called presenteeism. In the wake of COVID, however, this has changed.
Some dentist practices, in particular, have suffered financial strain due to COVID and related fallout, and many dentists facing COVID shutdowns and disabling conditions have simply decided to file disability claims. The same holds true for physicians. Our disability law firm is also seeing more claims for mental/nervous conditions than ever before.
Due to the financial pressures noted above, there has been a noticeable uptick in how aggressive insurance companies are being when investigating and administering own occupation disability claims.
Even if your claim was initially accepted for payment, that it not the end of the process as most disability insurance companies have decidedly changed their orientation to “claim duration,” which means a quick recovery and return to work. And companies are getting there through what they call “early intervention,” which means the development of information early in the claim, before the insured is represented, that will be helpful in securing a disability claim termination.
Additionally, starting in 2020, our law firm has also noticed that disabled physicians and dentists have started complaining more frequently that their purported “own-occupation” policies ended up not being what their agent described in terms of coverage/limitations. In the past, agents were held liable for even negligent misrepresentations, but the newer policies now contain language that protects the insurance companies and their agents from liability in this context.
While there are now countless different levels of “own-occupation” policies, nonengaged and/or poorly trained advisors are not explaining the nuances of each policy type to their clients, who are unfortunately being left with inadequate coverage if they ever become disabled.
The 5 Most Common Disability Claim Management Tactics in 2021
In the past, we have seen that insurers under financial pressure have simply wrongfully denied claims, and this still holds true to some extent. However, we are also seeing insurers engaging in other, more creative tactics to reduce the amounts they are paying out.
More specifically, we have noticed that:
1. Disability insurers are conducting more rescission reviews. “Rescission” is a legal principle that allows insurers to void a policy and avoid payment if there were any misstatements made in the policy application—typically in the health questionnaire portion. If an insurer seeks to rescind a policy, they will typically offer to refund your premiums, but in return require you to give up your policy and your disability claim. This is a complex area, and the rules regarding rescission vary in different jurisdictions. If you believe your insurer is conducting a rescission review, you should contact a disability insurance attorney immediately.
2. Disability insurers are approving claims, but refusing to pay benefit increases that the policyholder applied for. This is a similar tactic to the one above, but slightly different. Instead of using rescission to void the whole policy, the insurer seeks to void one or more increases to the base benefit of the policy. So, for example, if your initial benefit was $2,000 and you were later approved for an additional $8,000 in benefit increases, the insurer would approve the claim, but only pay $2,000/month instead of $10,000/month.
3. Disability insurers are seeking to invoke complex provisions to reduce or avoid payment. As we’ve discussed in prior posts, over the last several years disability insurers have made their policies more detailed and complex. New disability policies can contain complex formulas for calculating benefit offsets or partial disability benefits, and these formulas generally are based on the policyholder’s loss of income. However, different companies define “income” different ways in their policies, and these definitions can be vague or overly-generic. As a result, it is not uncommon for a physician or dentist to have income sources that are difficult to categorize under the express terms of the policy. In the past, insurers were more inclined to work something reasonable out in these circumstances; however, lately, they have been more inclined to try to take advantage of these gray areas and construe them in their own favor, to reduce or avoid payment.
4. Disability insurers are revisiting and reinvestigating claims that have been paying for years and years. We have also seen an increase in insurers targeting policyholders who have been on claim for years—particularly mental health claims and claims based on subjective symptoms, such as pain or numbness. The most common approach here is using their in-house doctors to conduct a paper review of the records that results in “uncertainties” about the “ongoing nature” of the disability, or the “scope of limitations.” The insurer then invokes the exam provision of the policy and sends the insured to a doctor of its choosing, who looks for any basis to claim improvement and find that the policyholder is no longer disabled.
5. Delaying claim decisions due to pending information requests. As noted above, some insurers have reduced their personnel at the same time more claims are being filed. Consequently, we are seeing that many claims are being delayed, particularly if the policyholder is not submitting correct documentation at the beginning of the claim. Many people expect the insurer to tell them what information is necessary, but under current circumstances, this is a recipe for going months without any benefits. It is much better to gather everything that is needed and produce it at the outset, to speed up the process and keep your claim from being sent to the back of the queue due to pending document requests.
Out of all of the companies, right now Unum is the company that is standing out as the most aggressive. Unum has been sanctioned in the past for its bad faith conduct, and is currently the disability insurer that comes up the most in our disability case alerts each week.
In the past, Unum has been the insurer that is most willing to take legal risk to avoid payment during times of financial strain. Consequently, we consider Unum to be a bellwether, of sorts, to gauge of how the industry is doing. If Unum is denying more claims and acting more aggressively, it may mean that the other insurers will follow suit in short order.
September 30, 2020 Milliman Survey
Several recent surveys of the major disability insurers may reveal why we are seeing the above trends.
For example, Milliman, a Seattle-based actuarial consulting firm, recently released an annual survey of the U.S. individual disability income (IDI) insurance market for the last five calendar years. Milligan surveyed 15 of the largest private disability insurers, including Ameritas, Guardian, MassMutual, MetLife, Mutual of Omaha, Principal, Standard and Unum. At the time, these insurers accounted for about 90% of the IDI market.
The report is quite comprehensive, but we found the following findings to be the most noteworthy.
- Overall, the new number of individual disability policies sold in the United States fell to 6.6% (to 270,000).
- The report showed that new annualized premiums from new policy sales increased 0.4%, to $402 million.
- Four companies issued over 40% of their new IDI annualized premium in 2019 to doctors and surgeons.
- In terms of the products offered by 14 companies (either in the policies themselves or as riders), 11 of them offered pure own occupation policies; however, only 8 offered pure own occupation policies for doctors.
- On average, 14 IDI companies ranked their satisfaction as 3.8 (out of 5) for profitability and 3.1 (out of 5) for sales results for 2020.
- The insurers identified unfavorable trends in the IDI market, including several around COVID-19, such as uncertainty surrounding COVID-19 and the economy (including lower interest rates and unemployment), the impact on sales, pandemic operational difficulties, and expected increase in lapses due to COVID-19.
- Other unfavorable trends identified by disability insurers included a 200% increase in claim notices resulting from COVID-19 and risk of disability due to potential exposure to COVID-19, low claim terminations, increasing prevalence in mental/nervous claims, and claim notices that have no premise of sickness or injury (rather claimed economic disability).
- According to this survey, the long-term financial health of the IDI market also faces several obstacles, including an aging distribution with inadequate succession planning, aging producers (with younger producers focusing on asset management), an aging distribution model, nonengaged advisors, and lack of knowledge and lack of training for agents.
GenRe Report
GenRe, a Berkshire Hathaway reinsurance company, also recently released a report that looked at the 2020 Individual Disability market. While this study looked at sales trends, it also confirmed that disability insurance remains a multi-billion dollar industry.
This study looked at Non-Cancelable, Guaranteed Renewable, Buy-Sell, and Guaranteed Standard Issue product lines for 2019 and 2020. Sixteen carriers (including Ameritas, Guardian, MassMutual, MetLife, Mutual of Omaha, Northwestern Mutual, Principal, Standard, and Unum) participated in the study. These 16 companies represent $5 billion of in-force premiums.
This study showed that the number of new policies sold by these insurers in 2020 fell 10.8% (to 245,851) and that premiums for the new policies fell about 7% (to $398.9 million). The benefit amounts for new policies totaled $1.6 billion.
Insurers reported that COVID-19 was responsible for the drop in new sales—in part because producers struggled to close sales without being able to meet clients face to face.
Despite the drop in new sales, the number of insureds letting their in-force policies lapse decreased—likely due to the increased financial uncertainty from COVID. As a result, insurers still realized a net-increase from prior years to the total number of people covered by individual disability insurance by about 1.2% (3.1 million people). Premiums for these in-force policies increased 1.3%, to $5 billion. Benefit amounts for in-force policies totaled $19.6 billion.
Non-Cancelable policies, which are policies that must be kept in force with the same terms and premiums as long as the policyholder makes timely premium payments, represented $4.3 billion (85%) of total in-force premium. Medical and 4A and above occupations accounted for 93% of non-cancelable new premium. Guaranteed Renewable, where the insurer has the ability to increase premiums, in-force premium was up by 3%, or to $701.3 million.
Outlook for 2022
Based on our recent experience and the surveys discussed above, it is clear that many of the major disability insurance companies are under financial strain right now. The volume of claims being filed appears to be going up, due to COVID, and the companies are not selling as many policies as they have in the past. Consequently, we expect that the disability claim trends we are seeing will continue into 2022.
If you feel that your insurer is delaying payment, or has wrongfully reduced your benefit, please feel free to contact one of our disability attorneys directly, for a free consultation.
Sources:
Allison Bell, COVID-19 Hangs Over Individual Disability Market: Milliman, Think Advisor, Nov. 30, 2021, https://www.thinkadvisor.com/2021/11/30/covid-19-hangs-over-individual-disability-market-milliman/
Roberta W. Beal, FSA, MAAA and Tasha S. Khan, FSA, MAAA, Milliman Report: 2020 Annual Survey of the U.S. Individual Disability Income Market, Sept. 2020
Allison Bell, More People Have Individual Disability Insurance: Gen Re, ThinkAdvisor, May 13, 2021, https://www.thinkadvisor.com/2021/05/13/more-people-have-individual-disability-insurance-gen-re/
Gen Re, U.S. Individual Disability Market Survey, Summary Report – 2020 Results, 2021
Can I Sell My Practice and Collect on My Business Overhead Expense Policy?
Business overhead expense (BOE) policies cover business-related expenses (e.g. rent, employees’ salaries, utilities, etc.) if the policyholder becomes disabled and cannot work. But can you sell your practice and still collect BOE benefits?
One dentist tried to do just that in the case of Richardson v. Guardian.[1] Dr. Richardson was a dentist and practice owner with BOE policies through Guardian. Dr. Richardson found himself unable to work due to a disabling condition and sold the stock in his practice to an employee. His employee worried that she would not be able to afford overhead while she increased her clientele and Dr. Richardson offered to cover the practice’s expenses for a period of time, believing that his BOE would cover these expenses. However, Guardian refused to pay BOE benefits.
When Dr. Richardson sued, Guardian pointed to policy language stating that the policy only covered expenses “which you normally incur in the conduct of your business or profession.” Dr. Richardson argued that this policy language was ambiguous and the phrase should be examined in light of the policies as a whole. He argued that “business or profession” applied to his circumstances because he remained contractually obligated to pay for the purchasing employee’s overhead expenses, even though he had sold the stock in the company.
The Court looked to the word “conduct” and “your [business]” in terms of plain meaning and ultimately ruled that the policies’ definition of covered expenses shows “the intention that the insured must actually be in business in order to incur covered expenses”. The Court concluded that Guardian did not breach its obligation under the polices because Dr. Richardson did not personally “conduct” a business or profession after he sold his stock.
This case highlights the importance of reading and understanding the terms of your policy and how they may affect your ability to file a disability claim before making any changes to your work duties or your practice (including selling it). If you have questions about how your BOE policy works, an experienced disability attorney can help you analyze the terms of your policy and determine the best transition plan for you and your practice.
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 claim has not received a full and fair review, an experienced disability insurance attorney can evaluate your claim and help you determine what options are available.
[1] Richardson v. Guardian Life Ins. Co., 161 Or.App. 615 (1999).
Long Term Side Effects of Chemotherapy – Part II
We previously wrote about how late effects of chemotherapy, that continue or occur after a cancer has gone into remission, may be the basis for a disability insurance claim. In particular, one late effect of chemotherapy can be neuropathy, which can be especially detrimental to practicing dentists or physicians. This condition is called chemotherapy-induced peripheral neuropathy (CIPN) and, although rare, can develop several years after treatment. While in most cases CIPN will dissipate over time, in some rare cases it is permanent.
Symptoms:
Common symptoms of CIPN include:
- Numbness, pins & needles in hands and feet
- Pain or burning
- Difficult picking up objects, buttoning clothing
- Ringing in ears or loss of hearing
- Vision changes
- Sharp stabbing pains in hands and/or feet
- Constipation/trouble urinating
- Muscle weakness and/or cramps
- Loss of balance or difficulty walking
- Feeling heat and cold (more or less than normal)
Symptoms are usually symmetrical and start at the fingers and toes. At its worst, CIPN can cause more serious problems such as changes to blood pressure and heart rate, trouble breathing, paralysis or organ failure.
Treatment:
There is no treatment that can repair any nerve damage, rather treatments are designed to manage symptoms and improve function, and can include:
- Pain medication
- Topical medications
- Physical or occupational therapy
- Vitamins
- Exercise
- Electrical nerve stimulation
For individuals, such as dentists, who rely on fine motor skills and acute sensation in their hands to perform their jobs, CIPN can be a particularly devastating condition and may prevent a return to work, even after cancer is in remission. If you have been experiencing CIPN and think that you may need to file a long-term disability insurance claim, please feel free to reach out to one of our attorneys directly.
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 doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.
Sources
American Cancer Society
National Cancer Institute
Dana Farber Cancer Institute
Brown TJ, Sedhom R, Gupta A. Chemotherapy-Induced Peripheral Neuropathy. JAMA Oncol. 2019;5(5):750. doi:10.1001/jamaoncol.2018.6771
Insurance Company Tactics: Trivializing Job Duties
Does your insurance company understand your job duties? If not, how much does it matter?
If you have an “own occupation” disability policy, it could be the difference between a benefit approval and a benefit denial.
Why is My Insurer Trivializing My Job Duties?
Your job duties are a critical component of an “own occupation” disability claim. For this reason, insurers may seek to misclassify or over-simplify your job duties to avoid payment.
One such example is the case Joyce v. Life Insurance Company of North America (LINA).[1] Joyce was a garbage-collection supervisor, or route manager. In 2016, Joyce was struck in the head by a tree branch during a storm. He suffered a concussion and several ongoing symptoms. These included cognitive dysfunction, headaches, visuospatial difficulties, visual problems, and frustration.
Joyce’s actual job included supervisory activities, interactions with workers, analyzing and solving problems and knowledge of equipment. However, LINA merely identified Joyce’s job as “laborer.” LINA then determined that Joyce could still perform “labor,” and relied on a paper file review of Joyce’s medical records to justify a claim denial.
The Outcome
Joyce took LINA to court, and the judge saw through LINA’s tactics. The judge recognized that LINA’s determination did not include the correct job description and noted that LINA had been selective in the records it chose to review. In this case, the court ordered LINA to reevaluate the claim, taking into account the proper job duties. However, it took a court order to ensure that LINA properly evaluated Joyce’s claim.
If you have filed a claim and feel like your insurance is misclassifying your job description and duties, please feel free to contact our attorneys directly to set up a consult.
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 insurer is not evaluating your claim under the proper standard, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.
[1] Joyce v. Life Insurance Company of North America, Civil Action No. 2:18-cv-1293, 2021 WL 493262 (W.D. Pa. Feb. 10, 2021)
Long Term Side Effects of Chemotherapy – Part I
Cancer is a common reason that individuals may need to file a disability insurance claim. However, once the cancer goes into remission, insurance companies may pressure a claimant to return to work—even if the insured has not yet returned to optimum health.
One reason that a return to work (or even to normal daily tasks) may be delayed or impossible is due to lasting side effects from chemotherapy. The aim of chemotherapy drugs is to kill fast-growing cells, like cancer cells. However, because the drugs travel through the body, they can affect other, normal and healthy fast-growing cells. Cells most likely to be damaged by chemo are blood-forming cells in the bone marrow, hair follicles, and cells in the mouth, digestive tract, and reproductive system. Some chemo drugs can also cause damage to the kidneys, heart, lungs, bladder and nervous system.
Side effects that take months or even years to go away are called late effects. Sometimes these late effects can last a lifetime and chemo can also sometimes cause delayed effects, including a subsequent cancer that can show up years later. Late effects of chemotherapy include:
- Dental problems
- Early menopause
- Hearing loss
- Heart problems
- Increased risk of other cancers
- Infertility
- Loss of taste
- Lung disease
- Reduced lung capacity
- Nerve damage
- Osteoporosis
- Bone loss and changes to the joints
- Brain changes (including memory loss, slowed processing, movement problems, personality changes)
- Eye problems (including cataracts and dry eye)
During cancer treatment, you will typically have frequent access to a treating provider who can provide other necessary paperwork to your insurance company during the course of a claim. However, this may not necessarily be the case when it comes to side effects of chemotherapy after remission. This can be true because many side effects don’t require constant medical monitoring and/or there is no specific course of treatment, or cure, available.
If you are experiencing late effects of chemotherapy and your insuring is challenging your ongoing disability claim, please feel free to contact one of our attorneys directly.
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 doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms
Sources:
American Cancer Society
Mayo Clinic
National Cancer Institute
MD Anderson Cancer Center
What Tactics Do Insurers Use to Deny Claims? A Case Study
Insurance companies utilize a wide array of tactics to deny claims, particularly when there is a lot of money on the line. In this post, we will examine a case where Prudential engaged in multiple tactics to wrongfully deny a claim.
Christopher Chapin was a software engineer diagnosed with several mental health issues, including depressive disorder, other trauma or stressor-related disorder and cognitive disorder. As a result of these conditions, Chapin found himself no longer able to work and filed a disability claim under his policies with Prudential.[1] Below are the several ways Prudential attempted to deny Chapin’s claim.
Ignoring Evidence of Disability
Under Chapin’s policy, he was considered totally disabled if he could no longer do the material and substantial duties of his regular occupation for the first 24 months of his policy. Chapin’s cognitive impairments prevented him from performing his job, due to deficits in psychomotor speed, attention, and immediate and delayed recall—all of which were required to be a successful software engineer. Chapin provided doctors’ statements and medical records and objective testing performed by his psychiatrist in support of his disability. Nevertheless, Prudential argued that Chapin could still work under the terms of his policy, using its own experts to challenge Chapin’s evidence.
Relying on Pure Paper Review
It is common for insurance companies to have their experts conduct a paper review claimant’s medical records, often in an effort to undermine them or provide a different opinion. Chapin’s records were reviewed by two doctors. The first reviewing doctor did not even perform a complete review of the records, as she failed to discuss testing done on Chapin. The second reviewing doctor, a neuropsychologist, dismissed the testing because it was done by a psychiatrist versus a neuropsychologist. The Court found that this questioned the reliability of the doctor’s peer review.
While insurers are not required to conduct independent medical examinations (IMEs) or rely solely on treating providers’ opinions, the Court in this instance found that “Plaintiff’s doctors are more probative and reliable than those contracted by Prudential to conduct paper reviews of medical records.”
Failure to Investigate Plaintiff’s Claims
While claimants hold the burden to prove up entitlement to benefits, the insurance company also has a duty to conduct an adequate investigation. Here, Prudential’s own expert indicated several times that independent testing could confirm or deny the validity of the testing already performed. Chapin’s own psychiatrist also indicated that more complex testing could be done. However, Prudential did not request any additional testing until seven months after the reviewing neuropsychologist conducted his peer review.
The Court held that Prudential cannot “shut [its] eyes to readily available information when the evidence in the record suggests that the information might confirm the beneficiary’s theory of entitlement.”[2]
Ignoring the Opinions of Treating Providers
As touched upon above, Chapin submitted evidence from his treating doctors (PCP and psychiatrist) and his therapist who all concurred that Chapin was suffering from mental illness and was unable to perform the substantial and material duties of his occupation as a software engineer. In fact, one of the reviewing physicians indicated that Chapin’s treating provider should be discounted just because he was the treating doctor. The Court found that “wholesale rejection of a treating doctor’s opinion without reason is unjustifiable”.
Surveillance
Insurers will often conduct surveillance of an insured and take the findings (often including video surveillance) out of context to argue that a claimant is not truly disabled or is malingering. As another example, insurance companies often scour a claimant’s Facebook and other social media pages in order to deny claims.
At one point, Prudential received information that Chapin was participating in physical activities. Prudential jumped on this and alleged that such behavior conflicted with Chapin’s claims that he was unable to work. (In spite of the fact that physical activity is thought to help those with depression). The Court found that “evidence that Plaintiff went skiing, hiking, and went to the gym twice per week is irrelevant to Plaintiff’s claim that he was unable to perform his job duties due to cognitive impairment.”
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 insurer is using any of the tactics above to evaluate your claim, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.
[1] Chapin v. Prudential Life Ins. Co. of Amer., No. 2:19-cv-01256 – RAJ, 2021 WL 1090749 (W.D. Wash. March 22, 2021).
[2] Id. citing Rodgers v. Metropolitan Life Ins. Co., 655 F.Supp.2d 1081, 1087 (N.D. Cal. 2009)
Ischemic and Hemorrhagic Strokes
Strokes are a leading cause of death in the United States as well as a leading cause of long-term disability. The majority of strokes (87%) are ischemic strokes. An ischemic stroke occurs when blood flow through the artery that supplies blood to the brain becomes blocked (often by a blood clot). A hemorrhagic stroke occurs when an artery in the brain leaks or ruptures. The leaked blood puts pressure on brain cells, causing damage that may be irreversible.
Signs
Signs of stroke include the following:
- Sudden numbness or weakness in the face, arm or leg (particularly on one side of the body)
- Sudden confusion, difficulty speaking or understanding
- Sudden vision trouble
- Sudden trouble walking, loss of balance, lack of coordination or dizziness
- Sudden severe headache with no underlying cause
Risk Factors
There are numerous risk factors for stroke, including:
- High blood pressure
- Heart disease
- Abnormal heart rhythms
- Cardiac structural abnormalities
- Diabetes
- History of transient ischemic attacks (often referred to as “mini-strokes”)
- High red blood cell count
- Lack of exercise
- Obesity
- Smoking
- Excessive alcohol use
- Use of illegal drugs
- COVID-19 infection
Age, genetics, gender, race, and location may also play roles in who will have a stroke. Having a stroke also increases your risk of having a subsequent stroke. In fact, nearly 1 in 4 people who have strokes have had a previous one.
Another risk factor is stress, including work place stress. Stress can cause inflammation and makes the heart work harder, blood pressure rise, and levels of sugar and fat in the bloodstream climb. These factors can increase the likelihood that a blood clot could form and trigger a stroke. Stress can also trigger many risk factors that can be associated with high risk for stroke, including eating poorly, smoking, alcohol abuse, and less time for exercise.
Complications
Complications of stroke include:
- Loss of muscle movement or paralysis (usually on one side of the body)
- Difficulty talking or swallowing
- Memory loss or thinking difficulties
- Emotional changes
- Pain, numbness or other unusual sensations
- Changes in behavior
- Changes in ability to self-care
Claims based on stroke, or even the need to limit work because of being at an elevated risk for stroke, can be nuanced, especially if a stroke isn’t completely debilitating and/or it is hard to objectively verify the extent of the ongoing limitations. If you’ve had a stroke and your insurer is challenging your disability claim and pushing you to return to work, please feel free to contact one of our attorneys directly.
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 doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms
Sources
CDC
John Hopkins Medicine
Banner Health
Cleveland Clinic
Mayo Clinic
What Happens if I Miss the Proof of Loss Deadline?
Most disability insurance policies have a Proof of Loss provision. Proof of loss refers to the need to submit supporting evidence of your disability claim. This can include claim forms, medical records, and test results. Proof of Loss requirements also usually state an amount of time you have to file a claim. But what happens if you miss this deadline?
Don’t Make This Same Mistake
Many physicians and dentists, understandably, want to keep working as long as possible. It can be hard to know when to step away. This can be especially true with slowly progressive conditions (such as many musculoskeletal issues) or if isn’t clear whether symptoms will be permanent.
A physician or dentist in this situation may begin working part-time in an attempt to “get by” and hope things improve. In fact, they may even think they are doing their insurance company a favor by delaying filing a claim, without realizing that their policy may allow partial disability benefits if they are working part-time. However, delaying a claim may impact your ability to collect full benefits.
One example of this can be found in the case of Hsu v. Northwestern Mutual Life.[1] At the time of his disability, Dr. Hsu was a physician specializing in interventional medicine.
Dr. Hsu suffered from constant right elbow pain, which was exacerbated with wrist extension and/or elbow flexion. Both activities were required in his profession. Although his disabling condition had begun much earlier, he didn’t submit proof of his claim application until June 2019.
The Proof of Loss Deadline
Dr. Hsu’s policy with Northwestern Mutual (NWM) required him to provide notice of a claim “within 60 days after the start of any loss.” If this was not possible, “it must be given as soon as reasonably possible.” Further, written proof of loss was required 90 days after the end of each monthly period for which benefits are claimed, or as soon as possible but “[i]n any event . . . no later than one year and 90 days after the end of each monthly period for which benefits are claimed.”
After reviewing the policy’s Proof of Loss deadlines, the Court determined that Dr. Hsu had filed late and could not obtain benefits prior to March of 2018. However, the results in these cases can vary based on circumstances and policy language.
The Takeaway
There are many reasons that a doctor might put off filing a claim. He or she might be busy seeking additional treatment in an effort to find a way to abate symptoms or trying to keep working as long as possible, despite symptoms that impede the ability to safely practice. However, delaying filing a claim may mean, as in Dr. Hsu’s case, that you miss out on benefits.
If you have questions about your disability policy’s Proof of Loss provision or the timely filing of a claim, please feel free to contact one of our attorneys directly.
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 insurer is not evaluating your claim under the proper standard, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.
[1] Hsu v. Northwestern Mutual Life, C20-88 TSZ, 2021 WL 735374 (W.D. Wash. Feb. 5, 2021)
Patrick T. Stanley Promoted to Equity Membership Firm is Now Officially Known as Comitz | Stanley
The Firm is Pleased to Announce Patrick T. Stanley has been Promoted to Equity Membership and the Firm is Now Officially Known as Comitz | Stanley.
Patrick Stanley has extensive experience assisting doctors with their own occupation disability insurance claims. His practice also focuses on assisting doctors, practice groups and healthcare-related businesses meet their legal needs. Mr. Stanley holds an AV Preeminent rating from the Martindale-Hubbell Law Directory and has been named “Best of Arizona” in Healthcare and Insurance by Arizona Business Magazine.
Attorneys Edward O. Comitz and Derek R. Funk Recognized by Super Lawyers for 2021
Attorney Ed Comitz has been named a Southwest Super Lawyer for 2021 for the tenth consecutive year for excellence in the field of insurance coverage. Attorney Derek Funk has also been recognized as a Rising Star in the field of insurance coverage by Super Lawyers.
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. The selection is a multiphase process comprised of independent research, peer nominations and peer evaluations. Only 5% of attorneys receive a Super Lawyers distinction, and only 2.5% of attorneys receive the Rising Star distinction.
Comitz | Stanley’s primary office is located in Scottsdale, Arizona and the firm also has a satellite office in Salt Lake City, Utah.
Significant Uptake in Physician Mental Health Claims in the Wake of COVID-19
Physicians, dentists and and other doctors are susceptible to mental illness, burnout, and stress, given the demanding nature of the field. This susceptibility has only become more pronounced in the face of the COVID-19 pandemic. According to MGIS, a national insurance program manager, claims for mental and nervous conditions ranked third among the top causes of long-term absences from work. Others in the top five for doctors include cancer, musculoskeletal conditions, injury and nervous system conditions (e.g., multiple sclerosis, Parkinson’s disease). This was an 85.8 percent increase from claims filed in 2019.
Recent studies throughout the course of the pandemic back up what MGIS data is showing. A Yale School of Public Health survey showed high rates of depression and PTSD, with nearly one quarter of doctors showing signs of probable PTSD. A Washington Post – Kaiser Family Foundation poll found that three in ten doctors and other health care workers have considered leaving their profession, 50 percent are burned out, and six in ten say stress from the pandemic has harmed their mental health.
As these studies show, stress, burnout and other mental illnesses have become an even bigger problem in the workplace during COVID-19—often leading to the need to miss work and sometimes the need to file a professional disability insurance claim. However, as you might imagine, mental health claims are often subject to heightened scrutiny by disability insurance companies and can be more difficult to prove up given their subjective nature. If you are a physician, dentist or other doctor with mental health concerns relating to COVID-19 and are and thinking of filing a claim, please feel free to contact one of our attorneys directly.
Sources:
Mental and Nervous Long-Term Disability Claims for Healthcare Professionals Jumped Significantly in 2020, Cision PR Newswire, August 17, 2021, https://www.prnewswire.com/news-releases/mental-and-nervous-long-term-disability-claims-for-healthcare-professionals-jumped-significantly-in-2020-301357045.html
Matt Kristoffersen, Burnout, Alcohol, PTSD: Health Workers Are Suffering, Yale School of Medicine, February 17, 2021, https://medicine.yale.edu/news-article/burnout-alcohol-ptsd-health-workers-are-suffering/
William Wan, Burned out by the pandemic, 3 in 10 health-care workers consider leaving the profession, The Washington Post, April 22, 2021, https://www.washingtonpost.com/health/2021/04/22/health-workers-covid-quit/
Coronary Artery Disease
Coronary artery disease (CAD), also called coronary heart disease or ischemic heart disease, is the most common type of heart disease in the United States. CAD is the result of plaque building up on the wall of the arteries that supply blood to the heart. This buildup can cause the arteries to narrow over time, partially or fully blocking the blood flow (atherosclerosis).
As the arteries narrow, some people may begin to experience chest pain (angina) or shortness of breath while others may have no symptoms at all. A completely blocked artery will cause a heart attack.
Symptoms
Symptoms of heart attack include:
- Chest pain or discomfort
- Weakness, light-headedness
- Nausea
- Pain or discomfort in the arms or shoulder
- Shortness of breath
- Fatigue
- Pain in the neck or jaw
Risk Factors
Risk factors for coronary artery disease include:
- High blood pressure
- High blood cholesterol levels
- Diabetes
- Being overweight or obese
- Physical inactivity
- High stress
- Unhealthy diet
- Smoking
- Family history
- Age (risk increase with age)
- Sex
Diagnosis
Several different tests can be used to diagnose CAD, including:
- Electrocardiogram
- Echocardiogram
- Exercise stress test
- Chest X-ray
- Cardiac catherization
- Coronary angiogram
- Coronary artery calcium scan
- CT scan
Treatment
Treatment for CAD can include:
- Medications
- Procedures to restore and improve blood flow (angioplasty and stent placement, coronary artery bypass surgery)
- Lifestyle changes (including a health diet, regular exercise, weight loss, and reducing stress)
For some, avoiding serious complications, including heart failure, may require stepping away from practice, even with treatment. If you have been diagnosed with coronary artery disease and are thinking that you may need to file a disability insurance claim, please feel free to contact one of our attorneys directly.
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 doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms
Sources
CDC
National Heart, Lung, and Blood Institute
American Heart Association
Mayo Clinic
Have I Changed My Regular Occupation?
If you are a licensed dentist or physician and file a disability claim, will your insurance company recognize your occupation as a “dentist” or “physician”? Not necessarily.
How is “Occupation” Determined?
Most disability policies look at what you are doing right before your disabling condition occurred (as opposed to your license or what you have done for the majority of your career) when it comes to defining your regular occupation. This can be problematic if you stop working, or change jobs or job duties prior to filing your claim.
One such example of this is the case of Hsu v. Northwestern Mutual Life.[1] Dr. Hsu, a physician specializing in interventional pain management, left his job to move to the west coast. Before he resumed practicing in his new location, he began to experience symptoms of constant right elbow pain that was exacerbated by wrist extension or elbow flexion. He decided to have surgery and then returned to work on a trial basis at a new practice.
Unfortunately, the surgery did not prove successful. Dr. Hsu found himself unable to work and he filed a claim with Northwestern Mutual Life (NML). After reviewing his file, NML determined that Dr. Hsu did not have a “regular occupation” because he was not working when he became disabled. As a result, NML denied his total disability claim.
Do You Know How Your Policy Works?
It is not uncommon for us to see similar situations to Dr. Hsu’s, where a physician or dentist has taken an extended break (whether because of a disabling condition or for an unrelated reason) only to later realize they cannot return to work and needs to file a claim. In fact, many policies have provisions that state if an insured is not working at the time of disability, their occupation will be considered that of a retired person. Of course, it is much harder to prove up that you cannot do the normal tasks of a retired person versus not being able to perform the duties of a practicing physician or dentist.
Other mistakes include significantly modifying job duties (e.g. doing exams only instead of all facets of dentistry) or taking on a new or side job in an attempt to make up for lost income. All these activities can significantly impact how your insurance company determines your occupation.
Oftentimes, dentists and physicians make this mistake because they assume that their policy only allows them to collect if they are severely injured or paralyzed and unable to work at all. However, many professionals have “own occupation” policies that protect them if they are unable to do their job, even on a part-time basis.
The Takeaway
In Dr. Hsu’s case, the Court indicated that whether or not Dr. Hsu had been a physician or had no regular occupation at the time of filing was debatable, and the case remains pending as of this writing. However, Dr. Hsu might have avoided the expense and stress of litigation if he had read his policy carefully, complied with its requirements, and properly timed the filing of his claim.
If you have a disabling condition and are thinking about filing a claim, please feel free to contact one of our attorneys directly.
Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If your policy’s terms are not what you expected, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.
[1] Hsu v. Northwestern Mutual Life, C20-88 TSZ, 2021 WL 735374 (W.D. Wash. Feb. 5, 2021)
Mental Health Issues in the Workplace
The Hartford, a provider of disability insurance, has released new research regarding mental health issues. The study shows the prevalence of both mental illness in the workplace and a stigma that prevents those facing mental health challenges from accessing care.
According to the study, which polled both employers and employees, 70% of employers reported mental health challenges among their employees, with 72% saying that stigmas around mental health prevented care. Twenty-seven percent of employees said they struggle with depression or anxiety most days or a few times a week, which was up 20% from March 2020.
Further, according to the study, there is a disconnect in how employers perceive the mental health issues versus how employees do. For example, while 80% of employers said their company culture has been more accepting of mental health challenges in the past year, only 59% of workers agree. Similarly, 78% of employers said workers had flexibility in their schedule to get mental health help, but only 58% of workers agreed.
The study also highlighted the economic impact of untreated conditions in the workplace, with 31% of employers reporting that employee mental health strain is having a significant or severe financial impact on their company. This is a 10-point increase from a March 2020 survey. Despite this increase, 70% of employers and 62% of employees felt that the workplace will become less stigmatized as a result of the pandemic.
Depression, anxiety, and burnout can all be causes of missed work and, in some, can lead to the need to file a disability insurance claim. However, such cases can be notoriously hard to prove up. If you have mental health concerns and are considering filing a claim, please feel free to contact one of our attorneys directly.
Source:
The Hartford Study: Majority of Employers Recognize Mental Health As A Significant Workplace Issue, Report Stigma Prevents Treatment, businesswire, https://www.businesswire.com/news/home/20210622005719/en/The-Hartford-Study-Majority-Of-Employers-Recognize-Employee-Mental-Health-As-A-Significant-Workplace-Issue-Report-Stigma-Prevents-Treatment
Unum Sued for Not Paying Analysts Overtime
Unum has been sued by one of its former disability benefit specialists for allegedly requiring its employees to work over 40 hours per week without overtime pay.[1]
The Plaintiff, Ms. Loomis, has claimed that Unum violation of the Fair Labor and Standards Act (FLSA), alleging that Unum should have been paying her, and other similarly situated employees, overtime pay. The FSLA requires that most employees in the U.S. be paid at least federal minimum wage for all hours worked and overtime pay for all hours worked over 40 hours in a workweek. However, there are some exceptions to this requirement, including for administrative employees. This, in part, can include employees whose job includes work “of office or non-manual work directly related to the management or general business operations of the employer or the employer’s customers” and “[t]he employee’s primary duty includes the exercise of discretion and independent judgment with respect to matters of significance”.[2]
Ms. Loomis’ argument, based on her and other former employees’ declarations, was that their primary job duty was to process disability insurance claims to comply with predetermined guidelines in a specified time frame and, regardless of their product area or level, “declarants had little authority to independently make decisions on claims and instead acted pursuant to policies, procedures, criterial and guidelines set forth in Defendant’s Claims Manual.”[3] Unum disagreed and argued that its analysts were administrative employees under the Act.
Despite Unum’s arguments, the Court ultimately allowed the suit to proceed and granted Ms. Loomis’ motion for conditional certification that employees (with job titles that included “Disability Benefit(s) Specialist”, “Disability Specialist”, Benefit(s) Specialist, Disability Claims Examiner”, “Disability Benefit(s) Claim Analyst, and “Life Event Specialist”) could be considered potential opt-in plaintiffs and should be notified as such.
[1] Loomis v. Unum, No. 1:20-CV-251, 2021 WL 1928545 (E.D. Tenn. May 13, 2021)
[2] U.S. Department of Labor, Wage and Hour Division, Fact Sheet #17C: Exception for Administrative Employees Under the Fair Labor Standards Act (FLSA).
[3] Loomis v. Unum
Can I File A Claim For Long-Haul COVID?
COVID-19 was uncharted territory in many aspects of our lives, and disability insurance claims are no different. Most individual disability insurance policies have an elimination period (often 90 to 180 days) that makes it difficult to file a claim based upon the COVID-19 infection itself. But what about situations where COVID-19 complications result in long-haul symptoms and limitations?
What is Long-Haul COVID?
Long haulers (also referred to as COVID-19 syndrome or long COVID) are individuals whose symptoms of COVID-19 don’t go away, at least entirely. Lingering health problems can last for months. The most common lasting symptoms are fatigue, shortness of breath, cough, joint pain and chest pain. Other complications can include breathing issues, heart problems, kidney damage, lost or distorted sense of smell and taste, neurological problems, autonomic nervous system symptoms, blood clots, mental health issues, and diabetes. Further, many long-term effects remain unknown as researchers continue to study the disease.
Long-Haul COVID’s Impact On Doctors Ability to Work
As you can imagine, these complications may make it more difficult for a physician or dentist to meet the demanding requirements of his or her work. Individuals may begin to take measures to try and push through and continue to practice. The most common scenarios we see are practitioners who modify their occupation by limiting the type of procedures they perform (e.g., doing only exams instead of extractions), reducing hours, or taking extended time away from the practice.
Will Reducing My Hours Hurt My Claim?
If you fail to file a timely claim and/or changes to your work schedule have gone on long enough, your ability to collect disability benefits may be jeopardized. Under most policies, your insurance company will look to what your job duties were immediately prior to filing for disability and you can modify your occupation if you are not careful. In addition, some policies (typically employer plans) require that insureds work a certain number of hours each week in order to be eligible for benefits. Under these policies, taking extended breaks may cause an insured to lose coverage.
This highlights the importance of having a transition plan in place, especially if you feel any effects of long-lasting COVID-19 and worry that you will no longer be able to work in your usual fashion for an unknown period of time. If you have questions about long-term symptoms of COVID-19 and your disability policy, please feel free to contact one of our attorneys directly.
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 doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.
Sources:
John Hopkins
Mayo Clinic
American Medical Association
I’ve Been Paid Benefits For Years– Why is My Insurer Asking for More Information?
If your disability insurer has reassigned your claim or is asking for more information than usual, your claim may be targeted for termination.
If you’ve been on claim for a while, it is easy to become complacent and forget that your disability insurer is constantly evaluating whether you remain entitled to benefits. However, if you do not take care to meet your ongoing proof of loss requirements, you may find yourself facing a claim termination the next time your insurer conducts a review.
Why Do Insurers Reassign and Revisit Claims?
Sometimes, insurers will conduct broad reviews of all ongoing disability claims for financial reasons, to see if they can save any money by denying claims that they are currently paying.
On an individual basis, claims may also be singled out for heightened review after an insurer does online or in-person surveillance, or if an insurer requests medical records and the most recent records are limited or vague. In this second instance, an insurer may challenge whether the policyholder has met the policy’s ongoing care requirements. Another common example that draws heightened attention to a claim is changing jobs or job duties during a claim.
My Insurer Wants to Conduct a Medical Exam–Is this a Bad Sign?
One example of this is the case of Jue v. Unum.[1] Dr. Jue, a dentist, was diagnosed with De Quervain’s Tenosynovitis. She became unable to work due to swelling and pain in her wrists and filed a claim under her Unum disability policy.
Unum approved the claim and, from 1998 to 2004, Dr. Jue submitted regular statements from herself and her physicians. These reports confirmed that her condition remained disabling. Then, from 2004-2011, Unum only required annual claimant statements and monthly income statements.
Dr. Jue changed doctors in 2012, and Unum began asking for physician statements from the new doctor. Then, in 2015, Dr. Jue took on some additional work responsibilities and was compensated for time spent on computer training. At the time, she was practicing as a dentist part-time, and did not want Unum to count the computer training income when calculating her partial disability benefits. This prompted Unum to reassign her claim to its “validation unit.”
In addition to evaluating the new source of income, Unum’s validation unit revisited the underlying medical condition. It referred her file to a physician to conduct a paper review and then required Dr. Jue undergo an independent medical examination. Unum’s doctor told her that she needed to have surgery, Dr. Jue refused, and Unum terminated her benefits, after paying her for over a decade.
The Takeaway
This case highlights the importance of always having strong evidence to support your claim, even if your insurer is not asking for it as frequently. Most disability policies pay on a monthly basis. Consequently, insurers can (and do) conduct renewed investigations, often without warning. Even if your condition has not improved, you may still face a termination (or lawsuit) if you are not prepared to prove you qualify for ongoing benefits.
If your insurer has increased proof of loss requests and you fear your claim may be being targeted for denial, please feel free to contact one of our attorneys directly.
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 claim has not received a full and fair review, an experienced disability insurance attorney can evaluate your claim and help you determine what options are available.
[1] Jue v. Unum Group, Case No. 19-CV-08299-WHO, 2021 WL 427640 (N.D. Cal. Feb. 8, 2021).
