What Every Dentist Should Know about
Dentist Disability Claims in 2023
A Q&A with Disability Insurance Attorney Derek R. Funk
Mr. Funk’s law practice focuses on “own occupation” disability claims filed by professionals. The majority of his clients are dentists, and he has been a guest writer in prior UDA Action magazines. Below, Mr. Funk discusses recent trends in the industry, and answers a few of the most common questions dentists ask him about the disability claim process.
What are the most recent trends you are seeing in disability policies issued to dentists?
When companies first began issuing private disability policies, the policies were much shorter. Companies were primarily focused on generating premiums and signing up as many dentists as possible, and less concerned about policy language.
This changed in the early 2000’s when insurers realized they had oversold the policies and began engaging in bad-faith tactics to deny claims. High-profile insurers, such as Unum, were hit with multi-million-dollar sanctions and jury verdicts, and some insurers determined the industry was no longer a good investment and left the industry.
The remaining insurers began modifying their policies to expand their investigatory powers and limit the scope of their financial liability. Over time, policies that used to be only a few pages transformed into 50-to-60-page documents, as the companies added language intended to make it much harder to collect, including:
- Adding additional requirements for qualifying for benefits, such as only paying total disability benefits if you are not working at all (in any capacity);
- Offsetting or reducing total disability benefits if your income from a new job (or sometimes income from other disability policies) reaches certain income thresholds;
- Limiting recovery for mental health conditions or conditions with subjective symptoms to a timeframe substantially shorter than the policy’s maximum benefit period (typically 24 months);
- Requiring formal interviews under oath (essentially equivalent to a deposition, even if no lawsuit has been filed);
- Reserving the right to require a wide range of in-person exams (e.g. medical examinations, functional capacity examinations, psychiatric examinations, vocational evaluations, and rehabilitation evaluations);
- Requiring you to seek treatment intended to return you to “full-time duties” or “maximum medical improvement;” and/or
- Requiring you to produce your taxes, profit and loss statements, billing codes, and other financial information for audit, upon request.
While this may seem daunting, it does not mean that you should give up or cancel your policies. If you are legitimately disabled, you can collect disability benefits.
That being said, insurers added these provisions for a reason, and they invest significant time and money into vetting dentist disability claims. As a whole, dentists tend to file more disability claims than most other professions, and each long-term, permanent dentist claim is a significant liability for the insurer. As a dentist, you should not be naïve to this, and should approach your disability claim with a similar level of seriousness and attention to detail.
What are the most common claim management tactics you are seeing right now?
In the past, insurers under financial pressure simply wrongfully denied claims, and this still holds true to some extent. However, we are also seeing insurers engaging in more subtle tactics to reduce the amounts they are paying out. For example, we have noticed that disability insurers are:
1. Conducting more rescission reviews. “Rescission” is a legal principle that allows insurers to void a policy and avoid payment if there were misstatements in the policy application—typically the health questionnaire. This is a complex area and if you believe your insurer is conducting a rescission review, you should contact a disability insurance attorney immediately.
2. Revisiting and reinvestigating claims that have been paying for years. We have also seen an increase in insurers targeting claims that have been paying for years—particularly mental health claims and claims based on subjective symptoms, such as pain or numbness. The most common approach is using 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 a basis to find that the policyholder is no longer disabled.
3. Delaying claim decisions due to pending information requests. Recently, more and more dentists are calling us because their insurers have not reached a claim decision after months and months of submitting documentation. Many dentists entirely rely upon their insurer to tell them what information is necessary, or fail to fully produce what is being requested. This gives the insurer an excuse to back-burner the claim, and can lead to an endless loop of follow-up requests from the insurer, if the insurer is seeking to delay or avoid payment. It is better to proactively gather and produce the relevant information to support your claim from the start, to avoid delays.
Do you have any tips for filling out disability claim forms?
1. Read each form through carefully at least one time before answering any of the questions. Most disability paperwork is divided by topic, and each section often has specific instructions that can be easy to miss. Often, different sections of the forms ask about different timeframes, and submitting complete and accurate timelines is critical when filing a disability claim.
For example, analysts determine your “occupation” and categorize claims based upon your pre-and-post-disability work history and activities. Most claims also involve several other key dates that impact preexisting condition limitations, whether you timely filed proof of loss, what your prior income should be for purposes of partial disability calculations, and the list goes on.
If you create confusion regarding your claim’s medical or occupational timeline, it can lead to significant delays and, in some instances, denials that can only be sorted out through lawsuits.
2. Review your answers to make sure they are not too sparse or generic. If you have not been involved in a disability claim before, some questions can seem overly intrusive. Over the years, we’ve become involved in several claims where dentists skipped questions and returned partially completed forms.
If you do not understand a question or why certain information is being requested, or are concerned that answering a question may expose you to legal liability, you should not answer without first consulting an attorney. However, if you are refusing or failing to provide relevant information, you are not only giving the insurer an excuse for delays, but potentially making it easier for the insurer to deny your claim.
3. Re-read all your answers to ensure they are accurate. Like other insurance forms, disability paperwork includes fraud disclaimers and fine-print stating that you carefully and accurately completed them, whether or not that is actually the case. Once you sign and submit your responses to the insurance company, your insurer (and courts) will hold you to those responses.
Additionally, each time you submit additional information or forms, claim analysts are trained to identify any inconsistencies with prior information in the claim file. If there are inconsistent answers, this undermines your credibility and can cause your claim to be flagged for heightened review, surveillance and possible denial or termination.
Do I need an attorney to file a disability claim?
Some claims may not require attorney involvement—for example, a loss of a limb or something very serious, such as paralysis from the waist down. However, most of our dentist clients have more nuanced conditions, such as slowly progressive radiculopathy due to degenerative disc disease. Others have conditions like a tremor, that may not prevent them from working in other jobs, but have a significant impact on their ability to work as a dentist. Or mental health conditions that cannot be verified by a single, definitive objective test.
If your claim is denied or you have a dispute over policy interpretation, you may need an attorney to become involved to resolve the matter. However, lawsuits with insurance companies can drag out over several years. Even if you prevail it can be an exhausting process.
It is more prudent to approach your claim carefully from the outset and address any concerns that the insurer may have over the course of the investigation itself. In our experience, the most common areas where complexities can arise in dentist claims include:
- The timing of the claim (particularly in situations where a disabling condition is slowly progressive);
- Claims made by dentists who own their practice and need to decide whether to sell, bring on new associates, or keep working in a limited capacity;
- Claims where the underlying condition is a diagnosis by exclusion;
- Claims involving multiple co-morbid conditions;
- Claims involving recommendations for or against surgery; and/or
- Claims involving mental health conditions.
This is not an exhaustive list, but if your claim encompasses one or more of these areas, it is a good idea to at least consult with a disability attorney to determine what issues may arise over the course of your claim.
* Derek R. Funk, Esq. is a Phoenix-based disability insurance attorney licensed in Utah and Arizona. He works with dentists at all stages of the disability claims process.
The information in this article has been prepared for informational purposes only and does not constitute legal advice. Anyone reading this article should not act on any information contained herein without seeking professional counsel from an attorney. The author and publisher shall not be responsible for any damages resulting from any error, inaccuracy or omission contained in this publication.