Physician Disability Insurance Claims

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 necessary 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.

To learn more about physician disability insurance claims and how we can help, contact Robinson & Warncke today.

Physician Disability Insurance Claims in Atlanta, GA

Doctor Disability Policies Tend to Be Rich in Features

  • 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.

What Is the Disability Claims Process?

The claims process will differ depending on whether or not you have purchased a private long term disability policy or you are covered by a group policy that is governed by ERISA. On the one hand, ERISA sets minimum standards for employee benefits. But on the other hand, it also acts as a means of shielding insurance providers from accountability.

If you have coverage under an ERISA plan, the process for filing a claim can become a drawn-out battle. In some cases, we can negotiate settlements, but in other cases, we will need to litigate the claim to ensure your insurance carrier pays out in accord with the policy and contract. Those who have purchased private policies that they have paid into over the course of the years generally don’t face nearly as much friction from the insurance carrier. Those insured under ERISA policies may have their claim denied over and over before their benefits are paid out.

Has Your Insurance Claim Been Denied?

If your insurance claim has been denied, it is not the end of the road. It is just the beginning. It is extraordinarily unlikely that an ERISA insurance claim will simply be granted the first time around. Even if you are filing under a privately purchased insurance policy, you will need to show that your disability prevents you from doing your job. In some cases, insurance companies will deny claims just to see what they can get away with. Or they may try to forestall the process of paying out on the claim. It’s bad practice and against the law, but it does happen.

Why Was My Disability Insurance Claim Denied?

Depending on the language of your contract, there are several reasons why an insurance company can deny a seemingly valid insurance claim. These include the following:

1. Your disability only prevents you from doing part of your job.

In cases where you are only partly impaired and can still do some of your job, the insurance company may claim that your disability does not rise to the standard of disability outlined in the policy.

2. You are not “fully disabled” under the policy’s language.

Policies can define disability however they please. You should review the language of the policy which is governed by contract law. It’s important to know exactly what the insurance company’s standard for disability is. That, in essence, will determine what standard of proof you will need to show in order for your insurance company to satisfy the claim.

3. You did not file the claim within the specified window of time.

Your policy should state when you have to file the claim in accord with the period of time you began losing earnings. In cases where you file too late, your claim may be denied. In these cases, you may have to forfeit some of your earnings or the date on which your payments begin will be later than they should have been.

4. The insurance company claims you failed to cooperate with their investigation.

This tactic is used to deny claims frequently. It is the tactic used when all other legitimate tactics have been exhausted. The insurance company will claim it does not have sufficient information to grant your claim. They will then repeatedly ask for more information. Regardless of how much information you supplied, they will claim it was less than the amount they asked for and say that you did not comply with their requests for information.

Insurance Companies Will Anything They Have Against You

In cases like these, the insurance company relies on emotionally exhausting you in the process of satisfying their requests. But if you have an attorney manage the process, it becomes much more difficult to get away with such tactics. In cases where an insurance company denies a valid claim, they can be sued by the claimant. Robinson & Warncke can help ensure that the insurance company is held accountable to the terms of the policy and operates in good faith.

It’s important to understand that the insurance company will not just investigate your medical records, but you too. If there is information on social media that can potentially jeopardize your claim, they will use it against you.

Physicians 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. They require creativity and careful attention to detail in order to get the best possible outcome.

Talk to a Physician Disability Insurance Claims Attorney

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. To learn more about physician disability insurance claims, contact Robinson & Warncke today.