The Insurers Strike Back: What to expect from your Disability Insurer when filing a claim.
In Part 1, we explored how aging physicians today may experience work-related and other health problems impairing their abilities to practice their specialties or to continue practicing at all. In Part II, you’ll learn what to expect from your insurer when confronted with a disability insurance claim.
Changes in the dynamics of the disability insurance industry over the last 10 or 15 years have caused your disability insurance company to become financially-driven. The reality is that “it’s all about the money.” When the disability insurance industry began to implode in the 1990’s, it first consolidated through mergers and acquisitions to pool assets and create better efficiency. When this failed to keep the companies profitable, they took a more aggressive approach in considering claims. The same physician group that was once aggressively sought after as the target market for sales of high-end disability policies has now become the target group for the companies’ aggressive claims tactics. The companies protect their bottom line by trying to keep big premiums coming in, while keeping big benefits from going out. So when you file a claim for benefits, you go from an asset to a liability in the eyes of your disability insurer.
The companies have acquired and developed many different “weapons” to use when considering your claim. After you have filed a claim, the Company can keep you as an asset by developing information to refute your claim. They will methodically attempt to accomplish this by interpreting its contracts, virtually on a line-item basis, to best suit the company. Any word, or even placement of a comma, makes a significant difference in whether they will ultimately be obligated to pay you benefits. The companies house an extensive staff of claims representatives, field representatives, investigators, medical experts and vocational consultants, and other support personnel to protect their financial interests. The companies also use highly credentialed, well-qualified, and forensically-trained external medical experts to “assist” the company in considering your claim. After you file your claim, your company will go through an extensive checklist of ways to defeat your claim, or secondarily, to reduce the amount of money it must pay you.
For example, to establish that you are totally disabled, a typical policy requires satisfaction of two contract provisions: 1) the inability to perform the material and substantial duties of your own occupation; and 2) receiving care by a physician which is appropriate for the condition causing the disability. On its face, this provision may seem clear, simple, and straightforward. Unfortunately, your company will make sure that that is not the case.
To be more specific, the first question is: what is your “own occupation”? Are you an orthopedic surgeon? Or while actually being a board-certified orthopedic surgeon, are you also an entrepreneur since you either solely or jointly own your practice? Or are you an administrator since you are chief of orthopedic surgery for your hospital? Or are you also a professor since you teach a course or instruct residents or fellows at a medical school or hospital? Or are you a lecturer since you present on behalf of a pharmaceutical company or companies? In addition, what is the actual role that you play in your practice and group, and how do you spend your time and generate revenues? The reality is that all these issues and more are carefully considered by your company in merely assessing the two words “own occupation.”
You must also satisfy the physician care provision. What is “appropriate care” and who is appropriate to provide that care? What type of treatment is appropriate and is the extent and frequency with which you receive it appropriate? The care provided by your treating doctor or doctors was once presumed by the companies to be appropriate. Now, appropriate care is what your company decides is “appropriate.” This usually includes care which is intended to return you to your own occupation, which, by the way, is always in the best interest of your company.
Those are just some hurdles faced when focusing on only one small part of a very large contract. But there are a multitude of defenses and company friendly court decisions that the companies may use in considering your claim. They may try to exclude your condition from coverage by concluding that it was a pre-existing condition. They may take the position that you are not factually disabled because multiple collateral issues — licensure issues, criminal charges, privilege issues, medical malpractice insurance and non-compete causes, etc. — actually prevent you from performing your duties.
Even if you are fortunate enough to get through the initial battery of “procedural” defenses, it’s still not over. The companies notoriously request unending and burdensome amounts of information which may be extremely difficult or even impossible to provide. Sometimes, disabled physicians may not have the fortitude to continue to fight the disability insurance companies with their endless resources and manpower at their disposal.
Even though you may have bought a “Cadillac” policy, your “warranty” may have been assumed by a “foreign” company. The “rules of the road” have changed over time. Buckle up your seatbelt and hold on for the ride of your life. What should you expect from your disability insurer when you file a claim? Everything.