A disabled doctor’s claim always involves unique issues and challenges. A doctor must be able to perform at a high level all the time – physically, mentally and emotionally. Therefore, doctors can find themselves disabled by conditions that might not interfere with less demanding occupations. A surgeon with numb fingers cannot perform surgery. Even a mild cognitive impairment might be sufficient to prevent a doctor from functioning at the level needed to be safe and effective. Understanding the intersection between the physician’s duties and his medical condition is at the center of every doctor disability claim.
In our experience doctors tend to spend a great deal of money to obtain the best possible disability coverage. It is a tremendous surprise and disappointment when expensive, high end insurance does not meet our client’s expectations.
Doctor disability policies tend to be rich in features such as:
- Benefits for life. Sometimes payment of lifetime benefits depends on how the disability arose, i.e., “Accident” versus “Sickness.” This can be a contentious issue in the claims process.
- Partial or residual disability coverage, providing benefits if a disability limits, but does not completely prevent, work.
- “Own Specialty” coverage, paying benefits if a doctor cannot perform work in his own specialty, even if he is able to perform work in another specialty or another occupation.
These policy features present unique proof problems and legal challenges. For instance, the question routinely arises whether a surgeon who cannot perform surgery is “totally disabled,” even if he or she can perform office duties. Another issue that seems to recur is, if a claim is presented after a doctor has already reduced his or her duties, should the disability be measured by the policyholder’s occupation at the time the policy was purchased, or by the reduced duties being performed at the time the claim is presented? An experienced disability lawyer should know how to answer these questions and deal with these unique policy features.
We have represented, among others:
- An obstetrician who had to stop working after his fourth back surgery. The issue was whether his disability was due to Accident or Sickness, with lifetime benefits at stake;
- An oncological surgeon with a spontaneously arising vestibular disorder causing dizziness and imbalance;
- An interventional radiologist with multiple medical issues limiting him to non-interventional duties only;
- A cardiologist with heart issues that caused him to have to change specialties to something less demanding;
- An orthopedic surgeon who could no longer operate, but who could perform office duties.
Particularly in claims where the doctor is able to perform some, but not all, of his or her duties, the claims process can be complex, time-consuming, and laborious. It is not uncommon for a disability carrier to insist on monthly reports of billing, revenue, and CPT codes, in addition to requiring a continual flow of medical information to document the disability. Oftentimes disputes arise as to the nature of a doctor’s pre-disability earnings and duties compared to the post-disability earnings and duties. These claims are uniquely challenging, and require creativity and careful attention to detail in order to get the best possible outcome.
We are often able to resolve these issues to our client’s satisfaction without having to initiate lengthy and costly litigation. Sometimes a dispute cannot be resolved through the claims process. Where litigation is necessary, we will pursue your claim aggressively, engaging all the resources necessary to achieve the best possible result.