The definition of disability included in your disability income insurance policy may be the most critical term in the entire insurance contract. This is particularly true in the medical profession where so many specialties exist and where the risk of disability from your occupation is high. Being insured as a general practitioner, when you are in fact a specialist, may not provide you with coverage truly insures your own occupation. Do you have true own occupation disability coverage? You may be surprised.
Several definitions of disability are available in disability income insurance policy. There is the definition of disability that has become known as the “own occupation” definition. Generally, under an “own occupation” policy, an insured is considered totally disabled if he or she becomes unable to perform the material and substantial duties of his or her occupation. There is also a “specialty” version of this “own occupation” definition, which requires an insurance carrier to recognize a specialty practiced by a professional as his or her occupation.
To illustrate the significance of “specialty” coverage, consider the example of an Invasive Cardiologist who performs primarily cardiac catheterizations versus a General Cardiologist whose practice consists of patient consultations and performing non-invasive diagnostic testing. An Invasive Cardiologist should make certain that he or she is insured against disability from Invasive Cardiology as opposed to General Cardiology, not only because the physical requirements are greater but also because the job duties required are different. Furthermore, the likelihood of an Invasive Cardiologist becoming unable to perform cardiac catheterizations is greater than developing an inability to conduct a patient consultation, stress test or EKG. If an appropriately drafted disability insurance policy is not secured, an Invasive Cardiologist could, due to illness or injury, become entirely unable to perform cardiac catheterizations and still not be considered occupationally disabled by his or her insurance carrier, despite this making up a significant portion of his or her practice. This is because the insurance company will assert that the terms of the insurance policy only require it to determine whether the medical professional is disabled from practicing Cardiology, not specifically from practicing Invasive Cardiology. In other words, the company can assert that because an Invasive Cardiologist can still conduct patient consultations and stress tests, he or she is not disabled as an Invasive Cardiologist despite the inability to perform cardiac catheterizations, which alone qualifies the professional as an Invasive Cardiologist. This would be extremely detrimental to a claim for disability benefits for a practitioner who only practices and specializes in Invasive Cardiology. An Invasive Cardiologist whose practice consists of primarily cardiac catheterizations would likely experience a significant decrease in revenues and patients as a result of being disabled from performing cardiac catheterizations.
Our client Doctor Williams was in fact an Invasive Cardiologist who became disabled from performing cardiac catheterizations. Doctor Williams’ practice consisted of seventy-percent cardiac catheterizations, prior to him suffering from a significant neck injury which caused him to be unable to wear the lead apron required in the “cath lab” and as such, disabled him from being able to perform the procedure. Doctor Williams filed for disability upon being unable to perform cardiac catheterizations. After all, Doctor Williams had invested many years of his income into an “own occupation” disability insurance policy in the event a situation such as this occurred. However, to Doctor Williams’ surprise, he was denied disability benefits. Doctor Williams contacted our office, inquiring as to why he had been denied disability benefits under his policy when he was disabled from performing a procedure that made up seventy-percent of his regular practice. Upon thorough review of Doctor Williams’ policy and denial letter, it was discovered that the reason that Doctor Williams had been denied was because his insurance carrier determined that he was still able to perform other duties (beyond cardiac catheterizations) that a Cardiologist performs, such as ECHOs, stress tests, EKGs and consultation type work. Dr. Williams’ carrier had completely ignored his specialization in Invasive Cardiology and, more specifically, in cardiac catheterizations.
Remember, Doctor Williams had an “own occupation” policy and not a “specialty” policy. As previously mentioned, the “specialty” policies are specifically drafted to require the insurance carrier to measure a professional’s disability according to his or her specialty. Without a policy including such language, many times the insurance carrier’s representatives misinterpret policy provisions and misunderstand exactly what a professional’s specialty entails on a daily basis. Other times, vague definitions of disability (i.e. lacking mention of specialty) are asserted by the insurance carrier in such a way as to be able to deny benefits, which is seen as a positive business decision for the carrier.
Doctor Williams retained Disability Insurance Law Group to represent him in his claim for disability benefits. Our office spent hours reviewing Doctor Williams’ disability policy, his carrier’s claim file, the correspondence between Doctor Williams and his carrier, the procedure codes, past and current scheduling books, and like records from Doctor Williams’ practice. Many more hours were allocated to holding conferences with Doctor Williams and also with his own medical providers, drafting an appeal portfolio with several exhibits, corresponding with Doctor Williams’ insurance carrier, among handling other critical aspects of the appeals process. After this extensive process with his carrier, Doctor Williams was paid the disability benefit to which he was entitled to receive under his insurance contract. Disability Insurance Law Group continues to represent Doctor Williams to ensure that he is paid disability benefits as required under his insurance contract and to handle all correspondence with his carrier, including monthly claimant’s statements, attending physician statements and other documentation required by his carrier for payment of his disability benefits.
Many specialists within the medical community do not have “specialty” disability policies and thus run the risk of not being insured as specialists, but instead as general practitioners whose duties are being generically defined by the insurance carrier according to industry standards. However, many other specialists within the medical community do have “specialty” policies. Yet even these medical professionals with “specialty” policies are being denied disability benefits because they many times file their claims in such a way as to allow the insurance carrier to argue the claim outside of coverage under the policy. Disability insurance contracts include very complicated terminology which can be misleading and is many times used by the insurance carrier to its advantage. Keep in mind that the insurance carrier is the party who drafts the insurance contract and thus, regardless of how seemingly “good” the policy is, terms within the policy are sometimes drafted in a purposefully ambiguous manner as to allow the insurance company flexibility in determining eligibility for a claim. While it can be positive for a policy to allow flexibility in claims handling procedures, the carrier’s representatives sometimes abuse this flexibility which creates an unfair advantage for the insurance company.
The definition of disability in your disability income insurance policy affects your claim with your carrier significantly. Moreover, the disability insurance experts that Disability Insurance Law Group works with have told us how critical the disability income insurance policy is to your claim. It could help you or harm you from the beginning until the end of your claim and can mean the difference between whether a case is approved or denied by the insurance carrier. Many professionals unaware of the importance of the application quickly, and often carelessly, complete the application for disability benefits. This coupled with the ambiguity in the terms of their policy can be devastating to their claim. For this reason it is essential that you take the time to understand your entire disability contract, thoroughly review all application materials, and pay special attention to the wording you choose when completing all forms. Remember, the insurance companies have the advantage of drafting the contract, and as such, you may wish to consider having someone versed in the area of disability insurance review your documents before entering into the contract or applying for benefits. Many of the problems which arise with disability claims can be avoided if the claim itself is handled appropriately. However, if you have already filed a claim on your own and have been denied, you may still wish to consider obtaining advice before proceeding any further.
If you have questions regarding your disability insurance policy or claim, please contact the attorneys at Disability Insurance Law Group at www.dilawgroup.com.