Dentists tend to have a much higher incidence of neck and back problems than the general population. Dentists are required to be on their feet for hours, often in non-ergonomic positions, while performing procedures on their patients. This takes a toll on the body over time.
Many dentists have the foresight to buy disability insurance early in their careers. They do this to protect themselves financially against a career-interrupting or career-ending injury or illness. Most buy these policies when they are young and healthy, often adding additional coverage as their income grows. Most dentists are lucky enough to never have a disabling medical problem. Others pay disability premiums for many years and have a medical condition that slowly (or suddenly) interferes with their ability to treat patients. Dentist disability claims present unique issues and challenges, and insurers often find creative reasons to deny these claims.
Disability insurance companies are usually good about paying smaller claims that are short-term in nature. They also tend to readily pay claims based on severe injuries that arise suddenly and obviously, as with traumatic events like car accidents. Conditions that arise gradually due to repetitive stress injuries seem to generate more disputes and controversy. Unfortunately, these are all-too-common with dentists.
Here, we’ll discuss a few things dentists need to know about filing a disability claim and what to do if your claim has been denied by your insurance company.
Is Dentistry a “Hazardous” Profession?
Dentists often endure repetitive stress injuries from having to sustain non-ergonomic, leaning postures for extended periods of time. The repetitive stress of holding these postures typically impacts the neck, back, and hands. Any one of these injuries can make it more difficult – or impossible – for you to do your job. On a long enough timescale, you may need surgery or extended physical therapy to address this type of injury.
According to the American Dental Association, two-thirds of American dentists reported neck and lower back pain as a major problem affecting their practice. Half of those reporting neck and lower back pain as a major problem reported that their pain ranged from moderate to severe. Research has traced this to ergonomic issues. In 2017, a research team led by Timothy J. Caruso, Tamara James and Robert Werner, M.D, prepared a paper analyzing the musculoskeletal issues facing dentists. The report indicated that sustaining awkward postures, muscle contractions, and repetitive stress injuries are often caused by ergonomic problems resulting from working in confined spaces.
The report highlighted some of the main risk factors for dentists:
- Bending, twisting, and otherwise assuming awkward positions while treating patients
- Old or dull instruments that require more physical force to use
- Poor lighting that requires dentists to assume awkward positions to see inside the mouth
To deal with these potential hazards, the report recommended that dentists seek the aid of physical therapists, chiropractors, and massage specialists.
Long-Term Disability Claims Denials
Filing a disability claim on your own insurance policy is not as easy as it sounds. The insurance company expects you to prove that your disability is real and that it prevents you from doing your job. For those who sustain obvious injuries, like the loss of a limb, it may be relatively simple to convince the insurance company that your disability is real. For those who suffer from repetitive stress injuries, psychiatric disorders, or other pain disorders, it can be much more difficult. We have seen claims disputed even where a dentist had multiple back surgeries with poor outcomes and clear, unequivocal support from the surgeon.
The key to a successful claim is the quality and quantity of proof you submit to your insurance carrier and tailoring it to your policy’s unique terms. The most common reason given for denying a professional disability insurance claim is insufficient objective proof of the severity of your injury or illness and how they impair your ability to perform your particular occupation.
Why are Long-Term Disability Claims Denied?
The most common reason is insufficient medical evidence. However, the medical evidence you think you need is not the same as the medical evidence that the insurance company is looking for. As an example, you may have severe pain in your neck that prevents you from assuming awkward positions. However, without proof of ongoing medical care, the insurance company will almost always deny your claim.
The insurance company will need to see evidence of visits to primary care physicians or related specialists on an ongoing basis. Other medical evidence will include MRI’s, X-rays, and other imaging tests to confirm the severity of the condition. The icing on the cake is objectively proving the extent of your work restrictions, i.e., how long or how forcefully you can perform a given physical work task. A formal functional capacity evaluation is the gold standard for measuring physical limitations, and is a highly advisable addition to your claim proof.
What you need to understand is that the insurance company will do look for any weaknesses in your evidence and use it to deny your claim. So you have to present it with a well-documented, ironclad case to actually receive the benefits you have been paying for over the years.
“Missing” Medical Records
Sometimes policyholders may believe that their doctors have sent all the necessary records to their insurance carrier, only to learn otherwise months later. This results in avoidable claim denials and delays. As attorneys, we take charge of the situation. We compile and review the records to ensure completeness, spot potential problems. Where appropriate, recommend or refer our clients for specific testing to supply “objective” proof of their impairments and the anatomical basis for them. If the treating doctor’s records do not contain necessary information, we reach out to the provider to obtain additional detail via report or recorded interview.
Insufficient Doctor’s Statement
If your doctor’s statement doesn’t include a description of how your condition would impair your ability to perform specific job activities, the insurance company will likely deny your claim. The disability questionnaires insurers send your doctors are often ambiguous and use loaded questions to encourage a response that will justify denying your claim. It is not uncommon for treating doctors who mean well and believe they are supporting their patient’s claim to answer these ambiguous and leading forms in a way that harms their patient’s claim.
Failure to Meet the Policy’s Definition of Disability
Depending on what kind of policy you purchased, your claim can be denied based on your coverage.
Typically, all long-term disability policies have language concerning the definition of “disability.” In some cases, you will be able to file a claim on your policy if you can no longer perform the tasks related to your current profession. In other cases, the policy language will include both tasks related to your current profession or another profession that is roughly as lucrative as your dental practice. These are known as “own-occupation” versus “any occupation.”
This is a common reason for a disability claim denial. We will talk more about this in detail below.
How Billing Codes Can be Used to Deny Your Claim
Insurers will rely on CDT billing codes to determine what you do with your day while you’re working. Insurance companies’ interpretation of billing codes commonly lead to unexpected or even bizarre conclusions – in insurance parlance, “determinations” that your occupational duties are far different from what you know them to be based on firsthand experience.
Indeed, state insurance regulators and federal judges have chastised insurance companies for misusing billing codes or blowing them out of proportion to dilute coverage. A common reaction we hear from clients is that they don’t even know where to begin to respond because the insurer’s CDT code analysis is so opaque and strange.
So, let’s say you file a disability claim with your insurance carrier. A claims manager reviews your claim, your duties, and your medical records. To determine what your duties are, they ask for several months worth of billing codes. The purpose here (ostensibly) is to determine what your duties are and whether your medical limitations interfere with you performing your duties.
Since the CPT codes are used to determine your duties, any evidence that you have been billing patients for work after the “date of disability” may be used against you. This is regardless of the fact that you may have others performing duties that you once performed. This is often an issue for oral surgeons who can no longer perform oral surgery but can perform tasks related to a more generalized practice.
In this way, specialists get edged out of their insurance policy, even when they signed onto the policy while they were performing specialist work they can no longer perform.
Further, specialists can be asked to provide months worth of CPT codes dating back before their injury prevented them from working.
Lastly, we have seen insurers claim that dentists who own multiple practices have “dual occupations” as dentists and “owner/managers.” This is based on the fact that many policies define the insured “occupation” as whatever the insured was doing as of the date of disability. So, even if you filled out your application for coverage when you were only treating patients, twenty years later the mix of how you spend your time might have evolved.
Why do insurers make this “dual occupation” argument? The duties of “owners” are far less physically demanding than those of practicing dentists. It allows the insurer to say, even while admitting restrictions that prevent patient treatment, that you are able to continue performing your sedentary “owner/manager” duties. This makes you partially, rather than totally disabled, which saves money for the insurance company at your expense. We have fought this battle more than once, and the reported cases involving this fact pattern are plentiful.
Long-Term Disability Insurance Carriers
Long-term disability insurance providers sell insurance packages to high-earning professionals. These include doctors, lawyers, dentists, executives, and more. These policies include highly-coveted terms such as “own occupation” provisions that care for dentists and their families while they’re out of work.
Below, we’ll take a look at some of the major companies and their track record honoring claims.
Guardian Life/Berkshire Life Insurance
In 2001, Guardian Life merged with Berkshire Life Insurance to become one of the major providers of professional disability insurance. These policies are primarily targeted to professionals.
Guardian can be extremely demanding in terms of the quantity and quality of evidence it requires before paying a claim. If you are presenting a claim to Guardian it pays to enlist the aid of a skilled long-term disability lawyer as early as possible in the process. Our firm has successfully assisted several dentists with claims at their inception. It is far cheaper top get the claim on the right track from the start than it is to fix a disputed claim later.
Northwestern Mutual Long-Term Disability Insurance
Northwestern Mutual insures a great many dentists and other professionals. Their policies are some of the most expensive in the market and widely considered to be some of the best. If you are covered by a Northwestern policy you have a legal right to expect that your coverage will perform up these expectations. In fact, this is a basic rule of insurance law. Insurance policies are almost always confusingly worded. Sometimes even experts have a hard time understanding, and disagree as to how the technical policy language should apply to a given situation.
Insurance law 101 helps in these situations. First, where the parties disagree how a policy terms should apply, the courts will adopt the interpretation that tends to effectuate reasonable policyholder expectations. The courts do not read insurance policies like experts, they read them the way a “reasonable layperson” would understand them. And where the court finds a policy to be susceptible to two or more reasonable interpretations, it will adopt the reading that broadens rather than restricts the coverage. This is based on the rule of “contra proferentum” (literally “against the drafter”). Since the insurance company drafts the policy, if its language is unclear then the insurance company should suffer the consequences.
Provident Life & Accident / Unum Group
Provident merged with Unum in 1999, to form UnumProvident Corporation. In 2007, the company changed its name Unum Group, a global provider of long-term disability insurance. In the process, Unum Group absorbed policies that were underwritten by Provident. It is now well-documented that these old policies were under-priced and that both companies have lost money on them for decades. Unum Group does not like these policies and goes out of its way to deny these claims.
As a result, Unum has faced several lawsuits alleging – and some proving via jury verdict – that they denied Provident policies in bad faith. In the early 2000’s Unum faces a nationwide market conduct investigation by most states’ insurance commissioners. This resulted in a Regulatory Settlement Agreement with 48 states whereby Unum and its affiliates paid a fine, agreed to re-review thousands of denied claims, and agreed to improve its claims handling practices.
Unum can still be difficult to deal with, especially on high dollar claims on the older, unprofitable policies. For instance, they may require you to see one of their own doctors for a physical. Ostensibly, this is to determine whether or not you have a disability, but you’ll be hard-pressed to find anyone who has ever had an insurance-company doctor say something that benefited their claim.
Unum also routinely employees surveillance and other surreptitious background investigations. The insurance company will scour your online social media accounts and even follow you with private investigators. It’s their right to protect their investment, but they sometimes overstep their bounds or simply interpret vague, indirect evidence in an inappropriate way. This surveillance can continue even after your claim has been granted. The insurance company can then use this as the basis for denying future payments.
The Standard Insurance Company
The Standard Insurance Company provides long-term disability insurance to hardworking professionals. Their approach to denying disability claims employs a small number of doctors who work for them. They review medical records and conduct physicals to discredit your own doctors and your own claims.
Protective Life Insurance Company/Great West
For more than two decades Great West Life Assurance Company insured the American Dental Association group disability plan. In recent years this company merged with Canada Life Insurance Company. Further corporate structuring means that your old Great West is probably now being handled by Protective Life Insurance Company.
We have seen some fairly aggressive and unusual positions being taken by this group in recent years. We have seen the company go back more than twenty years to look at policyholder income levels to dilute coverage. We have seen the company take very aggressive and questionable positions based on confusing and ambiguous policy language.
In our experience filing a claim with this company can be a very difficult and demanding process. We urge caution in trying to to it on your own. It is not always clear what Great West/Protective Life is trying to do when they start asking for far-reaching information. Let us help you by bringing our experience to bear on the situation.
Filing an Appeal After Your Claim Has Been Denied
It is highly unlikely that you will file a claim with your insurance company and that they will honor it without further bother. Denials are common. The language of your policy will include instructions on how to file an appeal. It is often at this stage when long-term disability lawyers are called in to help.
The policy is a contract and is therefore enforced via contract law. There are also federal laws (ERISA) that protect policyholders from bad faith denials – depending on the source of your coverage.
However, it is important to bear in mind that there are deadlines in the language of the policy. If you don’t appeal by the deadline, that language of the contract will prevent you from appealing again.
Robinson & Warncke help claimants like you file claims and receive the benefits that you were promised by contract. Sometimes insurance companies deny claims just to see if they can. They count on claimants throwing up their hands and becoming too frustrated by the process to continue. Stalling, asking for more information, or denying claims by denying claimants the benefit of the doubt are common tactics. But once you have a lawyer litigating the claim on your behalf, your insurance company will know that you’re serious. There is also the threat of being fined when denying claims in bad faith.
Talk to a Long-Term Disability Lawyer Today
Dentists, doctors, and lawyers purchase insurance policies to protect their income when they can no longer support themselves or their families. Insurance companies deny claims given only the smallest legal justification for doing so. If your claim is denied, you should consider coming to the table with some legal firepower behind you. Our Dentist Disability attorneys proudly represent policyholders in insurance claim disputes. Call us today, talk about your situation, and learn more about how we can help.