Physicians Filing Disability Insurance Claims
Most physicians, regardless of practice area have paid premiums for disability insurance for many years, hoping that they would never need it. Too often insurers treat claims, often reluctantly made by medical professionals, as opportunities to avoid paying benefits by playing on the insured’s inherent work ethic, pride, and professionalism. They question the claim, look for loopholes, and often wrongly deny disability benefits. For these reasons, it is important for physicians to be aware of the specific issues that arise prior to filing a claim for disability benefits.
Disability Insurance Issues Specific to Physicians
“Disabled” vs. “Partially Disabled”
Most older policies include definitions of “disabled” which entitle a physician to 100% of the benefits (for which they paid premiums, sometimes for decades) if they are unable to perform all the material duty of their specialty. Those policies often also include partial benefits for partially disabled physicians. Sometimes, insurers attempt to pay the physician partial benefits, when the physician actually meets the definition of “disabled” and is entitled to full benefits.
ERISA vs. Private Long Term Disability Policies
If the insurance policy is a group policy issued to a practice group it is likely to be governed by ERISA, a federal statute that has evolved through a number of federal court decisions into a powerful shield for insurers against accountability. Frequently, physicians suffering from disabling conditions will make claims (1) with the private policy they purchased individually, and (2) with the group policy acquired by the practice or hospital to protect and benefit the participants. Often, the private policy insurer will pay the claim promptly upon proof of loss, but the group insurer (ERISA) will deny all or part of the claim. This sometimes even happens when the insurance company is the same for both policies. ERISA imposes limitations on anyone trying to hold insurers liable for bad conduct, and this creates an incentive for insurers to deny claims.
Other Physician-Specific Disability Insurance Challenges
There are innumerable issues that arise when physicians make claims for disability insurance benefits. They relate to policy language, legal interpretations, local and national court precedent, industry practice, federal regulations, and factual specifics of each case. Professionals are a unique group of claimants in the disability insurance realm, and medical professionals are a very special and challenging sub-group, with issues specific to their profession, specialties, and the special policies marketed to them.
TYPES OF DENIED CLAIMS
DISABILITY CLAIMS FROM SURGEONS AND OTHER SPECIALISTS
Surgeons and other specialists spend a lot of time on their feet and/or leaning over patients. This, in and of itself, can lead to orthopedic and neurologic related impairments and limitations. Disability policy provisions vary in the degree to which they provide benefits, and the intricacies can present challenges. One example, of many, is the “Own occupation” definition of disability vs. the “medical occupation” definition. There are also claims that are denied simply because the occupation is considered sedentary or light.
ANESTHESIOLOGIST DISABILITY CLAIMS
Anesthesiology is a high pressure and often physically demanding specialty. Anesthesiology disability claims present a number of unique challenges, and insurers (more often than they should) perceive opportunities to deny or limit their coverage obligation, particularly when a claim involves orthopedic conditions, mental illness, or addiction.
WHAT IF MY DISABILITY INSURANCE CLAIM HAS BEEN DENIED?
Our attorneys represent physicians who have been wrongfully denied disability benefits. We understand the intricacies of disability insurance policies and the ways in which insurers try to use these intricacies to deny physician disability claims.
ATTORNEYS FOR DISABLED PHYSICIANS
We have helped medical specialists from a number of fields overcome challenges with insurance companies. These types of specialists include, but are not limited to:
- Orthopedic surgeons
- Hand surgeons
- Back surgeons
- Shoulder and knee surgeons
- Maxillofacial surgeons
- Obstetrics and gynecological specialists
- Primary care physicians
- Emergency care physicians
- General and thoracic surgeons
If you need assistance in filing a claim or appealing a denied disability insurance claim, contact us today for a free case evaluation.
« Return to the ERISA & Insurance Litigation Resource Center
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