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Long-Term Disability (LTD) Claims for Pediatricians

Leah Small

December 20, 2022

Updated: February 27, 2024

Long-Term Disability (LTD) Claims for Pediatricians

There are over 33,000 pediatricians working in the United States.  Families across the country rely on them for their children’s health and overall well-being.  However, when a medical condition or injury impairs a pediatrician’s ability to work, it can put not only themselves but their patients at risk.  In such cases, it is vital to consider filing for long-term disability (LTD) benefits.

Long-term disability benefits allow individuals to receive the care they need without worrying about their income.  While many dedicated professionals may not want to stop working, sometimes, unfortunately, it is necessary.

However, LTD benefits can be difficult to obtain as insurance companies are notorious for denying claims.  Thus, it is important for pediatricians to understand the claim process and what is needed when filing for long-term disability benefits.

Why Should Pediatricians File for Long-Term Disability Benefits?

Pediatricians are physicians who specialize in the healthcare of infants, children, and young adults.  As mentioned, they are a vital part of the community.  Parents bring their children and trust them to take care of them.  If a pediatrician were to try and work through a disability, they may make a mistake.  Moreover, they could place a patient in danger by giving the wrong medical advice, prescribing the wrong medicine, or reading medical files wrong.

Long-Term Disability (LTD) 101

In addition, pediatricians spend between 9 and 11 years studying before they may begin practicing medicine.  Others may study for upward of 17 years if they want to pursue a career in a subspeciality of pediatric medicine.  A disability can sideline a pediatrician’s career they have worked so diligently to achieve.

Long-term disability benefits can protect a pediatrician’s income.  Usually, coverage protects between 60 and 80 percent of their pre-disability income.  Of course, this percentage will vary from policy to policy.  Thus, it is important to thoroughly read your policy to fully understand the breadth of its coverage.

When receiving benefits, a person should focus their attention on managing their condition.  This can include receiving treatment from specialists and resting at home.  LTD benefits are meant to protect an individual for an extended period.  This period may be as short as two years but can also last all the way to retirement age.  Again, it is vital to read your policy to see the possible length of your benefit period.

The Occupational Duties of a Pediatrician

When filing a long-term disability claim with your insurer as a pediatrician, it is important to be cognizant of two points: the material duties of your job and how your insurer will determine the material duties of your job.

Pediatricians have several occupational duties.  These duties can include performing routine health and wellness checkups, conducting physical exams, tracking a child’s development over time, answering questions parents may have about their children’s health, prescribing medication, administering vaccines, and referring specialists as necessary.  Of course, these duties are just a snapshot of the full range of a pediatrician’s responsibilities.

It can also be beneficial to obtain a copy of your job description.  For example, showing up to work consistently on time is a duty that you may not think to mention.  Yet if you suffer from a debilitating condition, it may become impossible to reliably show up to the office every day.

Moreover, you may specialize in a certain area of pediatrics, such as neonatology, pediatric cardiology, pediatric oncology, pediatric surgery, pediatric pulmonology, and others.  It is important to demonstrate how your condition prevents you from performing your specialized duties as well.

The second point is how the insurance company will define a pediatrician’s occupational duties.  In the past, the Dictionary of Occupational Titles (DOT) was the standard resource for insurers.  However, the DOT has many shortcomings.  For example, the entry for “pediatrician” is a short, vague paragraph.  Luckily, the O*Net Database has largely replaced the DOT.

The O*Net Database is a much more detailed summary of the duties and skills a pediatrician has in their job.  However, you should still make note of your specific duties when you file your claim to ensure that nothing is overlooked.

What Types of Long-Term Disability Policies Are Available to Pediatricians?

Pediatricians may have either a group policy or an individual policy.  It is also possible to have both simultaneously.  A group policy is offered by employers, and is usually part of a benefits program.  Conversely, individual policies are bought directly from the insurance company.

How ERISA Impacts Long-Term Disability Claims

ERISA law is a federal law that governs group policies.  This is a complex and strict law that often benefits the insurance company.  Under ERISA, claimants must be aware of certain deadlines and regulations.  Failure to follow these regulations may result in a denial of a claim.

Individual policies are not subject to ERISA.  Moreover, these policies have more flexibility for policyholders.  Since the policyholder of an individual plan pays all the monthly premiums, they have more control over any modifications to their plan when they buy it.  In short, a person who buys an individual policy can shop around until they find the policy that suits them.

What Kinds of Conditions Can Qualify for LTD Benefits?

Some examples of conditions that can qualify for long-term disability include:

  • Leukemia
  • Lymphoma
  • Multiple sclerosis
  • Bell’s Palsy
  • Depression and anxiety
  • COPD
  • Kidney disease
  • ALS
  • Chronic pain
  • And others.

The above list is only a sampling of the wide range of conditions that can disable a person.  In short, if a condition makes it impossible for you to work for an extended period, then you may qualify for benefits.  However, to receive an approval for your claim, you must prove that your condition disabled you per the definition of disability within your policy.

The Definition of Disability

The definition of disability is an indispensable element within your policy.  You must prove to your insurer that your condition meets this definition by submitting evidence.  Many claimants rely on their medical records as their primary source of evidence, but some claims may require supplemental proof.

Definition of Disability in Long-Term Disability Policies Explained

Nonetheless, there are two common definitions of disability: own occupation and any occupation.  Own occupation definitions ask whether a person can perform the duties of their specific job.  Typically, insurance companies will define a person’s job by how others perform at that job in the national economy.  Some policies may refer to this definition as partially disabled.

Any occupation definitions ask whether a person can perform the duties of any job at all.  In other words, you may not be able to perform the duties of a pediatrician, but can you perform the duties of some sedentary job in an office?  Some policies may refer to this definition as totally disabled as the person must be unable to work in any job whatsoever regardless of its relation to pediatrics.

More specialized professionals—such as pediatricians—may have a gainful component along with an any occupation definition in their policy.  A gainful component considers a person’s skill set and experience and asks whether they can work a job that can pay a percentage of their income—typically 60 to 80 percent.  For example, if you make $200,000 a year, can you find gainful employment that pays you at least $120,000 a year?  If not, then you may still receive benefits.

Own occupation definitions are much easier to prove than any occupation definitions.  A gainful component does, however, make the any occupation a little easier to prove.  Regardless, even if you have an own occupation definition, it may transition after a set period—usually 24 months—to an any occupation definition.  Your insurer will reevaluate your claim and if your condition does not meet the new definition, they can terminate your benefits.

The Insurance Company May Deny Your Claim

Unfortunately, insurance companies routinely deny claims.  For pediatricians, as with other physicians, medical specialty may not be enough to obtain benefits.  For example, if you are still able to perform some of the duties of your job as a pediatrician—but not all—then the insurance company may argue you do not require benefits.  In this example, their main argument would be that the duties you cannot perform are not substantial enough to disable you from your own occupation.

5 Reasons Why Long-Term Disability Claims Are Denied

Thus, it is important to be thorough when detailing your specific duties so that it is evident why you require LTD benefits.  However, even if you are meticulous with your initial claim, your insurer may still deny it.  If this happens, you have the right to appeal this decision.

Your insurer will send you a denial letter.  You must review this letter to ascertain the reason for their denial.  Many claimants receive denials due to a “lack of evidence.”  Your insurance company may also have conducted surveillance on you.  This surveillance may be in person or online.  If they saw anything at all that could inject doubt into your claim, they will use it to justify their denial.

You should also request a copy of your claim file.  You should do this in writing and as soon as possible, as it can take upward of a month for you to receive it.  Under ERISA, you are entitled to your claim file for free.  However, you also must submit your appeal within 180 days of receiving your insurer’s initial denial.

Claim files are exceptionally long documents, sometimes over a thousand pages.  Reviewing it can be arduous, but it can help you form a carefully crafted appeal argument for your benefits.  A claim file will include all information your insurer has on you and your claim, including all correspondence; medical records; evaluation results; and more.

Can a Pediatrician File a Lawsuit in Court to Win Their Long-Term Disability Benefits?

Yes, a pediatrician may file a lawsuit in court.  However, when they may file this lawsuit depends on the policy they have.  For example, if a pediatrician has an individual policy, then they may file a lawsuit before filing an appeal.  Moreover, they may have their case heard in state court rather than federal court.

Litigation: What Happens When Filing a Long-Term Disability Claim in Court

If a pediatrician has a group policy, then they must exhaust all their appeals first.  Under ERISA, claimants may not file a lawsuit in federal court until they have appealed the insurance company’s initial denial.  Moreover, if their policy allows for multiple rounds of appeals, claimants must exhaust these as well.

Litigation, however, is often avoided through settlements.  The insurance company does not want to head to litigation.  It is often a long, arduous, and costly process.  Lump-sum settlements usually help avoid litigation in court, but claimants do not need to accept any settlement they do not like.

Litigation under ERISA is also difficult for certain procedural obstacles that are not present for individual policyholders.  There is no jury under ERISA, and you may not submit new evidence.  The judge has the final say on whether you receive your benefits.  Moreover, the standard of review for many claims often benefits insurance companies during litigation, not claimants.

Are Pediatricians Also Eligible for SSDI Benefits?

Pediatricians are entitled to SSDI benefits if they have a condition that renders them unable to work any gainful employment.  The condition must also be expected to last at least one year or result in death.

Insurance companies usually require LTD claimants to also file for SSDI benefits.  They do this because they want to offset your benefits.  However, the approval of SSDI benefits does not guarantee an approval of your long-term disability claim, and vice versa.

Social security disability insurance benefits have different requirements than your LTD claim.  Moreover, the definition of disability may differ between these two policies.

How Chisholm Chisholm & Kilpatrick Can Help with an LTD Claim

Obtaining LTD benefits is overwhelming for many claimants.  However, you do not need to file for such benefits on your own.  The experienced team of LTD attorneys at Chisholm Chisholm & Kilpatrick wants to help.  We understand how much time and effort has gone into being a pediatrician.  We also understand how devastating it can be to have to stop working a job you love.

Why It's Important To Have a Lawyer Help With Your LTD Claim

CCK’s long-term disability lawyers have over 30 years of combined experience.  They know how insurance companies operate and what they look for in a successful claim or appeal.

Our team can help you understand your LTD coverage, and we can handle all evidence and documentation on your behalf.  Additionally, we can act as a point of contact between you and your insurer.  We will track all deadlines and ensure that your claim is compliant with ERISA.  In short, we will help you avoid common mistakes that claimants make when handling their claims on their own.

Further, sometimes insurance companies continue to ask for information on your condition even after you have received benefits.  Some claimants may opt for CCK to continue representing them as they receive benefits.  We can continue as a point of contact and help you retain your hard-won benefits.  If necessary, we are prepared to represent you during litigation.

Call CCK Today for a Free Case Evaluation

CCK can help you at any point in the process.  As a pediatrician, you are entitled to LTD benefits under your policy, and we want to help you obtain them.

Call CCK today at (800) 544-9144 for a free case evaluation with a member of our team.  We will analyze your claim and see if we can help.

About the Author

Bio photo of Leah Small

Leah joined CCK in September of 2016 an Associate Attorney in the firm’s litigation practice and now serves as a Supervising Attorney. Leah’s practice focuses on representing individuals in the application, appeal, and litigation of life, health, short-term disability and long-term disability insurance benefits under the Employee Retirement Income Security Act (ERISA) and under private insurance contracts. Leah’s practice also includes litigation of personal injury, business, and contract disputes in both state and federal court.

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