As a physician, you spend years learning how to care for sick patients and truly spend your days saving lives. But, if you become unable to work due to injury or illness and want to file for disability benefits yourself, you may be surprised at how complicated the process will be for you.
In this article, we talk about:
- Why it’s so difficult to file a Long Term Disability claim as a physician;
- How to create a strong administrative file; and
- How you can obtain a professional evaluation of your disability insurance policy.
Why Is It So Difficult To Get Your Claim Approved As A Physician
Physicians face several challenges when filing for long-term disability. Why? Because the insurance company is looking at your case from a financial standpoint. They look at how much money it will cost them to provide you with benefits throughout your disability. The longer it could potentially take you to get back to work, the harder they will make it to get your claim approved.
Residual Benefit Rider
In addition to your regular salary, you may have a rider that helps recover what you have lost during your illness or injury. This would apply to physicians who have their own medical practice instead of working in a hospital. For example: if you are disabled for two years due to a major illness and come back to work, you probably have patients that had to seek medical attention from another provider; this rider will help support you while you rebuild your business and patient list.
Create a Strong Administrative File
Although you, as a medical professional, spend time noting your own patient’s pain levels and completing forms for disability cases, you might find it much different from being on the other side as the patient. A strong administrative file is key to winning a disability claim if it goes to court. Here are some things that need to be included in your administrative file:
- Copy of your long term disability policy. Knowing how your insurance company defines “disability” is very important to your claim;
- Copies of all letters from your insurance company and you to the insurance company;
- Why you can not perform your job duties (this will require medical documentation);
- A list of all medical providers that you have seen for this condition and a letter from each provider stating that your condition prevents you from working;
- Letters that summarize all conversations (by phone or in-person) between you and the insurance company representatives, nurses, doctors, and your employer. Send copies to all parties involved in the communication via certified mail as proof it was received;
- Keep everything chronological so that if your claim is denied, you have a complete record of how your claim was handled;
- Proof of your monthly earnings;
- Proof that you are under the care of a physician for your condition; and
- All medical documents from your physician regarding your condition, including but not limited to your official medical file, lab reports, X-ray and MRI reports, physician notes, and a list of surgeries including surgical reports.
Tips for a Successful Claim
Tip #1 Gather Strong Medical Evidence
Medical paperwork is the foundation of any long-term disability claim. Collect all the medical evidence from your doctors that are treating your disability. Be sure that your doctors are noting your pain levels and cognitive difficulties on your chart. This is not always common practice, but you will need detailed documentation for your claim.
For example, let’s assume a claimant has a significant back injury (such as herniated discs) and the claimant cannot sit, stand, or even walk for very long. The most comfortable position is for the claimant to lie down for 50% of the day to alleviate pain. There are not many jobs that will accommodate the need to lie down for half of the day. So the claimant will want to make sure there is good “objective medical evidence” to support the subjective complaints of pain. Objective evidence may include MRIs, X-Rays, etc.
Tip #2 Anticipate Surveillance
A large monetary claim – like one for a physician – will likely call for video surveillance. Surveillance is completely legal. During the surveillance period, a private investigator will stake out the claimant’s house, talk to nearby neighbors about the claimant’s daily activities, and then try to use that information against the claimant in the administrative decision (or in court); This is why it is crucial to not rush back into exercise routines or anything else that is very strenuous on the body during the claim period.
Tip #3 Stay Off Of Social Media
In our article about surveillance and long-term disability claims, we discuss the likelihood that social media accounts will be monitored. As a busy physician, you probably do not have much spare time for social media. However, when you are at home with nothing to do but rest, you may be tempted to start an account on a social media platform such as Facebook, Linked In, Twitter, Instagram, or Snapchat. We suggest staying off social media entirely during the claim period. The insurance investigator will try to use posts to social media accounts to deny your claim.
Tip #4 Do Not Try to Go Back to Work Too Fast
The amount of time spent recovering from a disability can be very dull and feel unproductive to a physician. The change from a very active schedule to weeks (and perhaps months or even years) of rest can feel like a prison sentence. Physicians must resist the urge to go back to work too early. When a physician pushes himself or herself back into work before his or her body is ready physically and mentally, the physician is in danger of making a mistake that could cause more harm.
Tip #5 Do Not Forget Cognitive Problems
An individual suffers from “cognitive impairment” when his or her ability to think and process information is reduced (for any reason). Examples include when the individual has difficulty with basic cognitive functions, such as memory processing, perception, problem-solving, and language. The symptoms of cognitive impairment may vary wildly from person to person; however, common symptoms include short-term memory loss and/or long-term memory loss; difficulty with planning, organizing, and problem-solving; confusion; an inability to handle stress appropriately; problems with managing time; and difficulty managing, influencing, and communicating with others. Cognitive impairment can even result in physical manifestations, such as causing poor motor coordination.
Cognitive impairment can arise from a number of severe and disabling medical conditions such as delirium, dementia, amnesia, Alzheimer’s disease, Parkinson’s disease, or Huntington’s disease. Cognitive impairments can also manifest as the result of other medical problems/diagnoses, including a stroke, heart disease, brain injury, major depression, an anxiety disorder, insomnia, high blood pressure, chronic migraine headaches, lupus, Raynaud’s phenomenon, and fibromyalgia. This list of causes is not exhaustive. There may be other diagnoses that cause cognitive problems.
While the language of every short-term and long-term disability policy is different, you are typically entitled to disability insurance benefits if you are unable to perform the material and substantial duties of your own occupation or any gainful occupation for which you are qualified by education, training, and experience.
It seems obvious that when a physician suffers from cognitive impairment, whatever the cause, he or she would have difficulty performing the material and substantial duties of a physician. However, insurance companies do not always pay benefits, even when their liability seems obvious. Too often, the attorneys at the Ortiz Law Firm have seen insurance companies/ERISA administrators assert that an insured has the “functional capacity” to return to work even if they are suffering from conditions such as cognitive impairment.
Note: An insurance company may require the claimant to sit for an “independent” neuropsychological examination. Keep in mind that this exam is conducted by a medical professional the insurance company hand-picked and the insurance company is footing the bill. As you can well imagine, the paid neurophysiologist often prepares a biased report concluding that the claimant has the residual ability to return to work, regardless of the limiting cognitive impairments from which they suffer. The Ortiz Law Firm has significant experience assisting claimants in this situation and has been successful in convincing insurance companies to reverse their denial decisions, even when that decision was initially supported by the results of an unfavorable neuropsychological examination.
The most common reasons for a claim denial are missing documentation, incorrect information, and missing deadlines. It is very important to provide everything you need for your case in a timely manner. An experienced attorney can help you gather documents and meet your deadlines.
Request a Free Policy Evaluation
If you are considering purchasing a disability insurance policy or have recently purchased a policy, we will help you understand what you are entitled to and whether there are deficiencies in your coverage that could lead to a denied claim. It is easy for individual policyholders who are not trained to read insurance policies to misread or misunderstand the disability policy. As part of our evaluation, we will explain what everything means to you in your situation.
Some of the aspects of your policy we will review include:
- Total versus residual disability;
- Own occupation versus any gainful occupation;
- Mental and nervous disability benefit limitations; and
- Self-reported conditions benefit limitations.
Fill out the form below to submit your request, and please allow 5 business days to receive your free Policy Evaluation Report.
Representation by an Experienced Long Term Disability Attorney
As a physician, it can be challenging to get a long-term disability claim approved due to the substantial cost to the insurance company. They will try to find any reason to deny your claim. By providing strong medical and financial evidence, you can create a solid administrative case file for your disability claim.
Using an experienced disability attorney will help you protect yourself against the insurance company and help you stay organized. The Ortiz Law Firm is based in Florida but represents claimants across the country. Receive a free consultation by calling (888) 321-8131 with no obligation. We can help you evaluate your claim to determine if you will be able to access Long-Term Disability Benefits and how to move forward with the process.