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ERISA Law

Long-Term Disability (LTD) Claims for Physicians

October 1, 2020
physicians standing in front of brightly lit window

Occupations in the medical field are both physically and mentally demanding.  Unfortunately, this means that disabilities are all too common, especially among physicians.  Given the years of hard work that goes into building a career as a physician, the prospect of being unable to work and needing to file a disability claim can be daunting and difficult to accept.  This article will address a few of the questions you may have about your long-term disability (LTD) claim.

How Can I Find Out More About My Long-Term Disability Coverage?

Before filing a long-term disability claim, it is important to understand what coverage is available to you.  There are typically two ways individuals obtain LTD coverage.  They can receive it as an employment benefit from work, known as a group policy, or they can purchase it directly from an insurance company, known as an individual policy.  Many physicians have both group policies and individual policies.

You can ask your employer for information regarding your employment benefits to determine if you have an employer-provided group policy.  Your employer should be able to provide you with the complete plan governing documents for each benefit plan you participate in, including long-term disability.

To determine if you have an individual long-term disability policy, you can review your financial records to see if there is evidence of premium payments to an insurance company.  If you do find evidence of such payments, you can request a copy of your disability policy directly from the insurance company.

Why Is It Important to Read and Understand My Long-Term Disability Policy?

If you have long-term disability coverage, the terms of your policy govern what you need to establish in order to receive the long-term disability benefits to which you are entitled.  It is important to read your disability policy in order to understand the definition of disability, deadlines, the maximum benefit period, limitations that may apply to your benefits, and other crucial information.

Although you may hope that you will never need to use it, you should proactively read your disability policy before you need to file a claim.  This will allow you to evaluate the coverage that will be available to you in the event you do become disabled, as well as purchase additional coverage if necessary.  Unfortunately, there are many claimants who do not read their long-term disability policies proactively, and then, when they need it most, are surprised to learn that they have a much lower level of protection than anticipated.

Definitions of Disability in Long-Term Disability Policies for Physicians

One of the most important pieces of information that your long-term disability policy contains is the definition of disability.  The definition of disability tells you the level of functional impairment you must meet in order to qualify for long-term disability benefits.  In doing so, it helps you identify what level of protection your policy provides, as well as what evidence you will need to submit in support of your claim.  When filing a long-term disability claim, you need to explain why you meet the applicable definition of disability and provide supporting evidence, including medical records, reports from your physicians, and statements from family, friends, or coworkers.

There are two definitions of disability that you will typically find in most long-term disability policies, although the specific wording can vary: the ‘own occupation” definition of disability and the “any occupation” definition.  Some long-term disability policies, especially employer-provided group policies, transition from the “own occupation” definition of disability to the any occupation definition after the claimant receives a certain number of monthly benefits.  However, many long-term disability policies that specifically cover physicians require the claimant meet only the “own occupation” definition of disability for the entire benefit period.

The “own occupation” definition of disability focuses on whether you are able to perform the material duties of your own occupation.  In other words: Can you perform the physical and cognitive duties required of the job you were doing at the time you became disabled?  “Own occupation” definitions of disability typically consider how your job is performed in the national economy, rather than how it is performed for your specific employer.

The “any occupation” definition of disability focuses on whether you are able to perform the material duties of any occupation.  Some “any occupation” definitions of disability include a gainful component.  This means that the definition of disability asks whether you are able to perform the material duties of an occupation that allows you to earn a certain percentage (typically 60 to 80 percent) of your pre-disability earnings.

What Issues Might I Face as Someone Who Worked as a Physician and Now Needs to File a Disability Claim?

Given the demanding and specialized nature of their work, physicians may face some specific issues when filing their LTD claims.

Medical Specialty and Identifying the Material Duties of Your Occupation As a Physician

Many long-term disability policies for physicians consider the physician’s medical specialty when determining their “own occupation.”  This can have a significant impact on their disability claim.  To illustrate this, below is a discussion of several medical specialties and the ways in which a medical specialty can affect a long-term disability claim.

Primary care physicians provide comprehensive care to their patients.  This frequently involves physically examining patients, which could require bending, lifting, sense of touch, and fine manipulation of fingers.  They provide general wellness and preventative treatment, as well as help monitor chronic conditions.  They also are often the first point of contact when their patients develop a new medical condition or issue.  Primary care physicians will often determine what other specialists their patients need to see and make the appropriate referrals.  Primary care physicians often have many patients and they must be well-versed in a variety of medical issues.

Emergency room physicians are responsible for treating and stabilizing patients who come to the emergency room.  This involves a wide variety of tasks including, but not limited to, examining, evaluating, and triaging patients; ordering diagnostic tests; treating illnesses or injuries by administering medications; suturing or stapling wounds; administering CPR or other resuscitation measures; or setting broken bones.  Emergency room physicians often deal with traumatic and life-threatening medical conditions.  They must work in fast-paced environments and be able to think and act quickly when a patient’s life is potentially on the line, as well as be comfortable working under pressure.  While emergency room physicians may not necessarily be “on call” outside of their scheduled shifts like other physicians are, they must still work long, often irregular, hours.

Radiologists are physicians who are responsible for analyzing and interpreting medical images, such as x-rays, MRIs, CT scans, and ultrasounds.  While some radiologists also perform the diagnostic imaging procedure, that is often done by radiology technologists rather than the physician.  Typically, after reviewing and analyzing the images, radiologists present their findings to the patient’s main treatment provider and may suggest potential treatments or further evaluations.  However, they are usually not responsible for providing medical care to the patient.  Radiologists must possess strong attention to detail and problem-solving skills.

Interventional radiologists are also trained in interpreting medical images, but they are additionally responsible for performing treatment procedures, using radiological imaging for guidance.  These are minimally invasive procedures that typically involve maneuvering small instruments, such as catheters and needles, through blood vessels or organs.  Common procedures performed by interventional radiologists include stenting, angioplasties, ablations, and thrombolysis.  Like general radiologists, interventional radiologists must possess strong attention to detail and problem-solving skills, but they also must be able to maintain the concentration and focus necessary to perform surgical procedures, as well as have the physical capabilities to maneuver the tools necessary to do so.

Orthopedic surgeons treat issues of the musculoskeletal system, or those involving bones, joints, ligaments, tendons, muscles, and nerves.  Specifically, orthopedic surgeons examine patients to diagnose the issue and recommend a treatment plan, as well as perform surgeries to correct the identified issues.  Some orthopedic surgeons focus on specific areas or bones in the body, while others are more general practitioners.  Orthopedic surgeons must have adept use of their arms, hands, and fingers, as well as be able to stand for prolonged periods of time while operating.   They must also possess strong critical thinking skills and the ability to maintain concentration and focus.  Depending on the environment they practice in, many orthopedic surgeons must also be willing to work irregular hours and be on-call at times to respond to any musculoskeletal injuries that may arise.

Anesthesiologists administer anesthesia (drugs that will reduce or eliminate pain sensations) to patients before, during, and after surgery or other medical procedures.  Anesthesiologists must not only administer the anesthesia, but also analyze a patient’s condition and medical history to determine which anesthesia to use, as well as monitor the patient’s status during the procedure to ensure that their vital signs remain stable.  Anesthesiologists must be able to think critically, problem-solve, and pay careful attention to detail.  While some surgeries are scheduled, many can arise without warning, and many anesthesiologists must work on-call shifts and be available to administer anesthesia when such unpredictable situations arise.

OB/GYNs are primarily responsible for providing two types of medical care – care for women generally and issues relating to their reproductive health, and care for pregnant women throughout pregnancy and childbirth.  These two roles result in a wide array of responsibilities, which can vary from performing basic physical exams, taking a patient’s history, and ordering blood tests or performing ultrasounds, to delivering babies or performing surgical procedures such as hysterectomies and biopsies.  It is physically demanding work, that often requires OB/GYNs to be on their feet for significant periods of time, as well as remain in prolonged, awkward positioning, such as the bending and stooping required for delivering a baby.  Like orthopedic surgeons and anesthesiologists, many OB/GYNs must work irregular hours with on-call shifts, given that childbirth is not always predictable.

This is not an exclusive list of specialties or requirements.  However, these examples make clear that many physicians have jobs that are both cognitively and physically demanding, although their specific duties vary widely within the various medical specialties.  The impact of this is twofold.

First, generally, such demanding occupations may not be sustainable with even a mildly impairing medical condition, making the “own occupation” definition of disability easier to meet for physicians than it may be for claimants in other occupations.  For example, even mild cognitive impairment, such as from a traumatic brain injury, could prevent a physician from reliably and consistently examining and evaluating patients, analyzing their medical issues, and recommending treatment plans.  Similarly, most physicians do not have a sedentary occupation.  As a result, if they have a condition that physically limits them to sedentary work, they are likely still entitled to benefits under the “own occupation” definition of disability, even though they are still capable of working.

Second, depending on the nature of your disability, your medical specialty could be the determining factor in whether you are entitled to long-term disability benefits, because what disables one type of physician may not disable another.  For example, emergency room physicians must work in fast-paced, high-pressure environments.  If you are an emergency room physician with a severe heart condition who can no longer tolerate stress, you may not be able to perform your occupation in that specialty, even if your heart condition does not produce any symptoms or physical functional limitations, per se.  However, for physicians who work in less stressful specialties, stress intolerance may not be sufficient to disable them from that medical specialty.

Similarly, if you are an interventional radiologist, OB/GYN, anesthesiologist, or orthopedic surgeons, you rely significantly on the use of your hands in order to perform your occupation.  If you suffer from cervical radiculopathy that results in finger numbness or weakness, you may no longer be capable of performing your specialty and thus be entitled to disability benefits.  On the other hand, a general radiologist who primarily analyzes and interprets medical imaging will likely be able to continue working in their specialty even with such issues.  Additionally, most primary care physicians must see and treat numerous patients throughout the day at a consistent pace.  But if you have significant fatigue, such as that resulting from sleep apnea or chronic fatigue syndrome, you may not be able to perform the back-to-back treatment of patients that your specialty requires.

Medical Specialty Alone May Not Be Enough for Some Physicians

Although medical specialty can be the determining factor in whether a physician is entitled to long-term disability benefits, often, a physician’s disability is not as clear cut as the above examples, and consideration of the specialty alone is not enough.  If you are able to perform some, but not all, of the services and procedures you previously did, the insurance company may try to argue that the services and procedures you are incapable of performing were not significant enough in your practice to disable you from your own occupation.  In those cases, it is necessary to identify the material duties of your occupation more specifically in order to demonstrate that you meet the applicable definition of disability.

For example, an orthopedic physician who does not perform surgery, but only sees patients in office, may still perform injections.  If he loses the ability to fine manipulate, and thus cannot perform injections, but can still perform general orthopedic exams and recommend a course of treatment, the question becomes whether injections were a sufficient portion of his occupation such that he should be considered disabled from that occupation.

There are several possible ways to identify the material duties of your own occupation.  Your job description is typically a good place to start if your hospital or medical office provides one.  Additionally, vocational experts can conduct interviews and analyze vocational evidence, such as labor surveys regarding the traditional duties of individuals working in your occupation, to determine the material duties of your own occupation.  Finally, for physicians specifically, CPT code reports can help identify what services or procedures you were performing prior to your disability, and how often, and thus demonstrate which services and procedures comprise the main duties of your occupation.

Review of CPT codes may also be necessary if you were performing some work outside of your medical specialty at the time your disability began.  Some disability policies require you to be performing a certain percentage of work within your specialty at the time disability begins in order for that specialty to be considered part of your own occupation.  For example, you may be a radiologist who is sub-specialized in interventional radiology and can no longer perform those procedures.  But if, at the time you became disabled, you were performing very few procedures and instead spent the majority of your time interpreting diagnostic images, your own occupation may be considered that of a general radiologist, rather than an interventional radiologist, and thus you may not be entitled to long-term disability benefits, even though you can no longer perform those procedures.

It is important to read your disability policy carefully to understand how “disability” and “own occupation” are defined.

Patient Safety Is a Priority for Physicians

Physicians are also in a unique position because they are often dealing with situations where they could put their patient’s life at risk if their treatment of the patient were interrupted or they were to make a mistake.  Consequently, even if you are capable of performing all of your duties some of the time, if you suffer from a medical condition that occurs unpredictably and would place patients at risk if an event occurred while you were providing treatment, then you may still be entitled to long-term disability benefits.

For example, if you are a surgeon who suffers from seizures or episodes of low blood pressure that cause you to collapse unpredictably (syncope), then you cannot safely operate.  Similarly, if you are a surgeon who suffers from migraines that cause visual impairments, you may be incapable of reliably and consistently performing your duties because you could make a life-threatening mistake if a migraine were to occur while you are operating.  Alternatively, you are an anesthesiologist who is responsible for providing spinal/epidural injections, you may not be able to do so reliably, consistently, and safely if you are starting to suffer from unpredictable hand tremors during the early stages of Parkinson’s Disease.

What Other Benefits May Be Available to Me?

In addition to long-term disability benefits, you may also be eligible for Social Security Disability Insurance (SSDI) benefits.  There are many rules that apply to SSDI claims, but generally you are entitled to benefits if you cannot perform any substantial gainful activity and your disability is expected to last for at least one year or result in death.  Because of the different rules that apply to each claim and the fact that the definition of disability for SSDI purposes can be vastly different than the definition of disability under your LTD policy, it is possible to be disabled for purposes of LTD benefits, but not SSDI benefits, and vice versa.

What Do I Do If My Long-Term Disability Claim Is Denied?

You have the right to appeal the insurance company’s decision if your long-term disability claim is denied or your benefits are terminated.  If you need to file an appeal, you should consider contacting an attorney.  The time to appeal is limited and the administrative appeal could be your last opportunity to get evidence into the record.  Whether you need help with an initial claim, the administrative appeal, or court litigation, Chisholm Chisholm & Kilpatrick LTD can help you obtain your long-term disability benefits.  If you need assistance with your disability claim, no matter where you are in the process, contact us at 401-331-6300.  We would be glad to review your case and determine if we are able to assist.