Disability Insurance Claim Advice
Disability Claims for Dentists, Surgeons, and Chiropractorst
California Broker, September 2007
By Art Fries
Many workers are still able to function on the job or perform in a reduced capacity with cervical, thoracic, or lumbar problems. But, disability claims are different for dentists, surgeons, and chiropractors. They can be devastated professionally if any of these medical symptoms become chronic and affect their performance.
The repetitive movements that some professionals make in performing their duties on a daily basis strains parts of their bodies. As a result, they may hold back with respect to procedures or may not be as effective in treating patients. Pushing themselves to do a proper procedure can put added stress on injured areas, which could lead to permanent damage. The professional can sometimes continue working part-time. But, in other situations, it’s necessary to stop performing clinical duties or go on total disability.
Many individual disability policies provide partial and total disability benefits, often to age 65 and sometimes for life. The working is often “occupation specific,” meaning that the insurance company pays the full monthly benefit if the claimant is unable to perform the substantial and material duties of their profession, but can work in another profession or job. The claimant’s ability to work in the new job must be consistent with the symptoms that disabled them from their profession.
Although an insurance company may have made certain promises in the way of a disability contract, these broadly worded policies have left a trail of red ink that has caused claim management practices never envisioned by professionals when the policies were purchased. To control the flow of money from their banks, many insurance companies are using defensive measures that make the claim process more difficult for the claimant. These measures include a field investigation (a personal visit with the claimant), independent medical evaluations (a medical exam by a doctor whom the insurance company selects and pays for), functional capacity evaluations (tests conducted by a physical therapists, which the insurance company selects and pays for), video surveillance, and the use of forensic certified public accountants.
An insurance company representative or outsourced representative may make an unannounced filed investigation or set up an appointment with the claimant. The insurance company sometimes asks the claimant to sign a handwritten statement prepared by the field investigator, which summarizes aspects of the claim. The claimant should never sign his statement at the interview, but read it carefully and return it to the investigator on another day with appropriate corrections.
Insurance companies are performing independent medical evaluations with most claims even when the claimant’s attending physician can verify symptoms. They are also using functional capacity evaluations more frequently, but typically with claims related to musculoskeletal (cervical, thoracic, low back) and hand and arms problems. I question how insurance companies can require a functional capacity evaluation. The policy language often states that the insurance company has the right to examine the claimant, but it does not say that the insurance company has the right to test the claimant. A functional capacity evaluation is a test.
Insurance companies use video surveillance to determine if the professional’s medical symptoms conflict with their lifestyle and actions. The companies monitor athletic and social activities closely early on, and may have multiple periods of video surveillance over the life of a claim. Often, a video surveillance team can even gain access to a guarded and gated community.
Insurance companies are using forensic certified public accountants more frequently on partial (residual) disability claims in order to dispute pre-disability earnings and post-disability earnings that the claimant has provided. The claimant’s CPA may have been overly aggressive in filing a tax return and made incorrect deductions. With a partial disability claim, it takes longer to agree on the percentage of earnings that the insurance company requires to arrive at the amount of money it will pay. A compromise can sometimes be made to arrive at a figure that’s acceptable to both parties.
The claimant should never discuss any calculations related to financials (tax returns and so forth.) over the phone. Instead, the claimant should ask the insurance company to provide any questions in writing for their accountant to review. CPAs for both sides can then discuss the matter.The claimant should be given guidance to understand the significance of certain questions on the claim form. How a disability claim is submitted and how the claimant acts in their personal life can determine whether they get paid by the insurance company. Most attending physicians don’t know the difference between a workers’ compensation claim, a Social Security disability claim, and the claimant’s personal or overhead disability policies.
