A common tactic used by insurance companies to deny or reduce doctors’ and dentists’ disability benefit payments is by reclassifying a specialty practice as generalist.
Does your LTD policy protect the income you make in the specialty or sub-specialty you practice in? If so, do not let your guard down believing that your policy can protect your rights to disability.
Many insurance companies have a game plan for redefining a doctor or dentist’s recent work from being a specialty practice to a more general practice. One version of this tactic involves reclassifying a specialty, such as an orthopedic surgeon, as a ‘general practitioner” or “practicing medicine.”
An even subtler version of this denial tactic concerns generalizing a sub-specialty into the broader specialty — such as reclassifying the occupation of orthopedic surgeon as a general orthopedic.
Such changes in classification can produce a disastrous loss of benefits to the physician, and insurance companies may go to great lengths to prevail.
For example:
The insured is a gastroenterologist, preforming colonoscopies and endoscopies as his main source of revenue. He is struggling with rheumatoid arthritis. As the condition worsens, pain, fatigue and other complications are preventing him from practicing his specialty medical procedures. But it has not yet forced him out of practicing in his specialty field.
He is still able to practice gastroenterology generally, seeing and diagnosing patients. But he no longer performs colonoscopies, as he feels he is losing the specific motor skills and physical and mental stamina required to do those procedures.
The insurance policy in this case is written to cover the physician’s specialty occupation as gastrointestinal surgeon. The doctor assumes that when he does file for disability, because he cannot perform colonoscopies and endoscopies, he will be covered. In the meantime, he believes he is right to continue working in a modified manner.
However: in dealing with his chronic condition, he has inadvertently shifted his practice to compensate for his disability. If he was a GI surgeon before he started to become disabled, for the past 10 months he has taken a break from surgical procedures and has done only clinical work.
Now, when the doctor applies for disability benefits, the insurance company is able to seize this opportunity to claim that he is not an operating gastrointestinal surgeon, and therefore not eligible for disability benefits.
By reclassifying a specialist’s past work as a generalist in this way, the insurer protects its bottom line with no regard for consequential loss of income to the disabled surgeon.
How the Insurer Proves a Specialty Practice becomes Generalist
The claims examiner will delve into what the doctor’s occupational activities and duties for those past several months actually were. They will look for information such as financial and tax records, clinic-related information and billing codes. They will investigate how many patients he was seeing, how profitable the practice has been, and other activities during that time when he was becoming disabled.
All of this information is compiled to present the picture that the claimant’s medical occupation is a general gastroenterologist. By reclassifying a surgeon or dentist – who rely on their hands, bend over patients in difficult postures, and require great mental focus and physical stamina day after day — as generalist, the insurer has a way to deny costly disability benefits, or at least reduce the value of the benefit payment.
This tactic can also be an effective delay tactic causing great frustration and complications to the claimant.
For a free legal consultation, call 800-562-9830
Economic Impact when a Specialty Practice Is Reclassified as Generalist
In addition to outright claim denial, insurance companies may award lower, residual disability benefits as a way to avoid paying the surgeon’s full benefits.
Residual disability is generally structured so that, if you cannot earn at least 60% to 80% of your former salary, you can get residual (partial) benefits because of that reduction in income – because you have lost that key component of your job which is the surgery component.
For surgeons and dentists, reclassifying a specialty practice as generalist can mean devastating financial loss without an alert, experienced doctor disability claim lawyer protecting your rights.
This is a very common and unexpected situation facing medical professionals. Some insurance companies will disregard what the policy intends, denying the claim on the grounds that the doctor is not disabled from practicing in his specialty field of medicine.
If the insurer does grant residual disability benefits, the doctor often does not come close to receiving the disability benefits he deserves.
Our Disability Attorneys Are Prepared for This.
We have extensive experience combating this and other denial tactics launched specifically against physician’s or dentist’s disability claims.
The key to prevailing is proving the economics of the case. Our law firm works closely with economists and vocational experts to show the economic differences between the medical specialties and sub-specialties, and the broader medical fields.
Always be mindful of what your occupational duties are during the time of disability, should you suspend your specialty duties to compensate for a disability.
If you are a doctor or dentist struggling with a medical condition that is obstructing your ability to perform surgery or other essential duty in your medical specialty, contact Marc Whitehead & Associates for a free case evaluation and to discuss the specifics of your doctor disability insurance claim.
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