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Long-Term Disability (LTD) Claims for Physicians

Mason Waring

October 1, 2020

Updated: January 24, 2024

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 demanding 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.

Long-Term Disability (LTD) 101

You can ask your employer for information regarding your benefits to determine if you have employer-provided group coverage.  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.  It is important to note that ERISA governs most group policies — a strict federal law that often benefits the insurance company.

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 to receive the long-term disability benefits to which you are entitled.  It is important to read your disability policy 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 long-term disability insurance 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 to qualify for long-term disability benefits.  In doing so, it helps you identify what level of protection your policy provides and what evidence you will need to submit in support of your claim.

Own Occupation Insurance Claims: What Are They?

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 co-workers.

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 over a period of time.

However, many long-term disability policies that specifically cover physicians require the claimant to meet only the “own occupation” definition of disability for the entire benefit period.

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 when they need to receive benefits.

Physicians and Long-Term Disability 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.

For example, 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.

Likewise, emergency room physicians are responsible for treating and stabilizing patients who come to the emergency room.  This involves various 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.

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.

Medical Specialty Alone May Not Be Enough for Some Physicians

A physician’s disability is not always clear-cut, so the consideration of the specialty alone is not enough.  If you can perform some, but not all, of the services and procedures you previously did, then 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 to demonstrate that you meet the applicable definition of disability.

5 Common Conditions for Long-Term Disability Claims

For example, an orthopedic physician who does not perform surgery, but only sees patients in office, may still perform injections.  If they lose 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 their occupation such that they should be considered disabled from that occupation.

There are several 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.

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, 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.

What Happens If the Insurance Company Denies My LTD Claim?

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 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 (800) 544-9144.  We will analyze your case and determine if we can assist you.

About the Author

Bio photo of Mason Waring

Mason joined CCK in 2008 and is a Partner at the firm. He has an active civil litigation practice in the federal and state courts, focused on representing individuals in the application, appeals, 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. Mason’s practice also includes litigation of personal injury disputes. Nationally, Mason represents claimants in ERISA and non-ERISA administrative appeals of denied benefits.

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