Whether a claim denial involves true, transitional, or modified “Own Occupation” coverage; or “Any Occupation” coverage, the issues at the core of the typical dispute overlap.
1. The common issues in the physician’s disability claim dispute
Sometimes the principal argument in a claim dispute is whether the language of your policy actually provides true own occupation coverage. Key provisions can differ from policy to policy, depending on when they were written and what company wrote them. The precise policy provisions, the policy definitions of any defined terms, usually capitalized in the provisions and defined in a separate section of the policy under the heading “Definitions,” and how courts have interpreted the same or similar provisions in other cases are key.
Don’t think the insurance company will overlook any opportunity to argue these points to avoid paying your claim. Denial disputes may involve some or all of the following issues: the policy definition of “Own Occupation”, and whether it is defined in terms of the physician’s specialty or sub-specialty, or more generally; what exactly are the material and substantial duties of the physician’s “Own Occupation” as properly defined; what are the physician’s true physical or mental restrictions or limitations (including any medication side-effects) in light of the illness or injury at issue; and whether those limitations cause inability to carry out those duties.
If the physician’s regular occupation is a specialty or sub-specialty requiring skills and capabilities the doctor is disabled from performing, but not required in a broader occupational category, the insurer will argue “Own Occupation” to mean the broader category.
Aside from the arguments over whether a physician’s specialty or a more general categorization of physician is appropriate for analysis under the policy provisions, commonly in dispute are the physician-claimant’s restrictions and limitations. The insurance company will usually use the opinions of one or more physicians it contracts to review your medical records to determine your restrictions and limitations, which often contradict the disabled physician-claimant and his or her treating physicians on the issue.
2. Examples of typical physician’s disability claim dispute fact scenarios
As an example, say the physician’s regular occupation may be “urologist,” requiring surgical skills. The insurer will try to categorize his or her occupation generically as a “physician”. If a hand injury would disable the physician claimant from his true occupation as a urologist, but not from the occupation of a family practice physician, an insurer may argue that he or she can still work as a “physician,” and therefore is not disabled under the policy.
As another example, in a recent actual case, the insurance company denied disability benefits to an emergency room cardiologist because he could perform the duties of a cardiologist if not emergency-room based. The court disagreed, holding that emergency cardiac patients required physical capabilities from which the doctor was disabled, that were beyond those required of non-emergency room cardiologists. Therefore, the court found the physician totally disabled from his occupation as an emergency room cardiologist despite his ability to still be a cardiologist.
3. Our emergency room physician client’s recent dispute with Prudential is a classic example
As another example, we recently won an appeal for our client, a Texas emergency room physician, who fought to continue working for as long as he could after major cervical and thoracic spine issues ultimately required multiple surgeries fusing levels C2 – T3. His duties required quick thinking and rigorous physical action, performing orthopedic dislocation reductions, intubations, placing central lines, and lumbar punctures. He also regularly encountered combative intoxicated and drug-altered patients.
His post-laminectomy syndrome pain and medication regimen took their toll. He began to falter physically and mentally until it became impossible for him to safely perform the material and substantial duties of his specialty. Unrepresented, he filed for long-term disability insurance benefits with Prudential after years of premium payments. He explained to Prudential that his pain and increasingly limited mobility endangered his patients. His own treating surgeon opined that he had become “increasingly reliant on a chronic pain regimen, including opioids and other controlled substances to function in even the most basic manner…” and suffered slow, clouded and unreliable thinking as a result. Our physician figured there was no way in the world he’d be denied. Everything he submitted was absolute truth.
But Prudential had its own doctor review his medical records. Without even bothering to meet with our client, Prudential’s physician opined that he could continue his full-time duties as an ER physician. Prudential credited its record reviewer’s opinions over the opinions of our client and his treating providers and denied the claim.
We filed his ERISA-mandated pre-litigation appeal, loading the administrative record with better objective and opinion evidence of his disability, along with more detailed sworn testimony from our client explaining exactly how his restrictions would endanger patients under different specific example scenarios. Prudential reversed its denial, and our client will now be paid monthly through retirement age.
Unfortunately, cases like these are far from unusual. When insurers like Prudential deny physicians’ long-term disability claims, they hope their insured will just “appeal” by arguing disagreement with the denial. They know that ERISA law prohibits the court from considering any evidence not submitted with the appeal before filing suit (most people don’t realize this until it’s too late). Loading the administrative record with the best evidence during the appeal process before filing suit is a critical step to getting claim denials like these reversed, whether on appeal, or in court if the insurance company denies your appeal.
Read on to learn the best process that you, as a doctor, can follow, and common mistakes you need to avoid along the way, to get your claim approved and win the disability benefits you paid for and deserve.