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. For that reason, dentists tend to have a higher incidence of neck and back problems than the general population.

Many dentists have the foresight to buy disability insurance early in their careers 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 slowly (or suddenly) interfere with the success of the practice. 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 or claims for 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 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 substantial 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.

Key to the process is what kind of proof you submit to your insurance carrier.  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.

What you need to understand is that the insurance company will do everything in its power 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 have the insurance carrier claim it never received them.  This results in avoidable claim denials and delays.   As attorneys, we assist our clients in compiling and reviewing the records to ensure completeness, spot potential problems, and, where appropriate, recommend or refer our clients for specific testing to supply “objective” proof of their impairments.

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 harm’s 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 billing patients for work you say you cannot do will be used against you when filing the claim. 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.

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.

Often, those who are filing claims on their insurance policy are told that they have a “dual occupation” if they perform duties related to their profession yet outside the typical scope of their profession.

As an example, let’s say that you’re a surgeon. While your disability prevents you from performing surgery, you can still do duties related to general care and diagnostics in an office setting. The insurance company will then claim you are not “disabled” according to the terms of your policy, even though you can no longer perform the occupation you had when you purchased the policy.

If your claim has been denied in this manner, you can leverage the insurance company to pay up with the aid of a skilled long-term disability lawyer.

Northwestern Mutual Long-Term Disability Insurance

Northwestern Mutual has a different approach to denying claims. They will generally 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.

From there, they will exploit ambiguities in the language of your policy, or ambiguities in your medical record to discredit your claim. In cases where they can’t discredit your claim, they will simply say that there isn’t enough medical evidence to support the claim. This can include saying that your injury is “somatic” or “functional” (ie: psychiatric).

If you pass these first two barriers, you will have to pass a third: Surveillance. 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 the evidence in a way that discredits their claim. 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.

Provident Life & Accuity / Unum Group

Provident merged with another company, 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. Unum Group does not like these policies and goes out of its way to deny these claims.

As a result, the Unum Group has faced class-action lawsuits alleging that they denied Provident policies in bad faith. In most cases, this involves stalling the process indefinitely and dragging their feet with their responses. These tactics include asking for information you already sent or not being specific about what information you need to provide to receive your benefits.

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.

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.

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.