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The Fundamental Flaw in Utilizing CPT Codes to Analyze a Physician's Pre-Disability Occupational Duties When an Insurance Company "Investigates" a Disability Insurance Claim

For years, insurance companies have aggressively marketed their disability insurance coverage to physicians, specifically targeting "specialists" with attractive "Own Occupation" protection. They induced physicians to purchase disability insurance with liberal definitions of Total Disability, such as "the inability to perform the material and substantial duties of Your Own Occupation," explaining that if they could perform the duties of an alternative occupation, even one within the medical community, but could not continue to engage in their previous occupation, they would be eligible for benefits. The most coveted of these policies specifically protects the ability to engage in the physician's actual specialty. However, many physicians have found that the promises made to them when they purchased the coverage were not honored when they actually became disabled.

When a disability insurance claim is filed, the insurance carrier will "investigate" both the claimant's medical condition and limitations and the duties of his or her Occupation just prior to the disability. The purpose is to determine whether the claimant's limitations prevent him or her from engaging in their actual occupational duties. While a physician may be Board Certified in a particular specialty, if he or she is not practicing within the scope of his specialty, it is not considered to be his or her Own Occupation. For example a physician can be a Board Certified Orthopedic Surgeon. If he or she spent the last 7 years only performing medical examinations for an insurance company, his or her specialty may be in Orthopedic Surgery, but his or her Own Occupation is that of a non-invasive medical examiner.

In investigating a physician's pre-disability Own Occupation, very often a carrier will either significantly focus its evaluation on or exclusively look to CPT codes to define the physician's pre-disability occupation. The problem is, in many circumstances, a significant focus on CPT codes is a fundamentally flawed way to evaluate a physician's pre-disability occupational duties. In fact, in many cases, if the insurance company predominately considers CPT codes to define what the physician's occupational duties were prior to his or her occupation, this will serve to unreasonably and inappropriately classify the physician out of his or her actual specialty.

Take for example a physician who is Board Certified as an interventional cardiologist. She becomes unable to perform interventional cardiology procedures in the catheterization lab due to a knee and back injuries, but can now work as a general cardiologist. The claimant asserts that she is Totally Disability under her Own Occupation policy. The insurance carrier reviews the pre-disability CPT codes and alleges that the claimant was cardiologist, who also performed interventional procedures because it determined that the majority of the CPT codes were "non-surgical" in nature.

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