Disability insurance policies are based on the concept of total disability and residual disability.
How these terms are defined and interpreted have great impact on claims filed by surgeons, dentists, nurses, chiropractors, and others who literally use their hands in precision movements, their bodies in chiropractic adjustments, or spend hours holding tiring postures through complex procedures.
A focal point in disability cases is the definition of total disability, and variations thereof.
Doctors and dentists often purchase disability insurance under an own occupation policy. These policies are often specialty-specific. Hand-in-hand with “own occupation” coverage is the policy definition of Total Disability.
Under a true own occupation policy, the physician is totally disabled and eligible for full monthly benefits if he or she can no longer do the principal duties required of their regular occupation.
Further, the disability policy may define “regular occupation” very specifically, such as ophthalmological surgeon or podiatric surgeon. The basic premise of “own occupation” insurance is that the disabled physician is unable to perform “all” duties in his or her specialty, or cannot perform the “substantial and material duties” of the occupation.
Total Disability under Group Insurance Policies
A typical group policy will have a “modified” own-occupation definition of total disability for the first two years of a claim, with wording to this effect:
Because of sickness or injury you cannot perform the material and substantial duties of your occupation due to illness or injury, and you are not engaged in any other gainful occupation.
After two years, your occupation definition changes to any occupation:
Because of sickness or injury you are unable to perform the material and substantial duties of your occupation, or any occupation for which you are deemed reasonably qualified by virtue of your age, education, training, or experience.
This shift is a root cause of thousands of disability claims being terminated under group policies. The determination of whether or not you are disabled is largely left up to the insurance company.
For a free legal consultation, call 800-562-9830
Tactics to Reduce Benefits
Sometimes an insurer will attempt to refer to the insured’s occupation as the work they were doing just prior to filing a claim.
We see many cases where doctors who, although disabled, choose to fight their disabilities. They will continue to work but in a lesser capacity. Physicians and dentists will find work-arounds, such as only seeing patients in the office as opposed to performing surgeries or procedures, or working fewer hours. When they do finally file a disability claim, they are working in a much different manner than their “regular occupation.”
This gives the insurance company the opportunity to claim the doctor’s occupation is part-time, or to redefine the doctor’s specialty as confined to in-office patient care.
These are just a few of the insurance denial tactics insurers use that can drastically jeopardize a high disability benefit payout.
Putting Our Experience to Work for You
Speak with a highly disciplined and competent legal team today. If you have questions about being denied total disability, we are here to help.
Our doctor disability claim lawyers will study your policy’s language and definitions to identify whether the denial of your claim is justified under the terms of the policy. We examine the insurance company’s documentation and look into the insurer’s claim handling methods.
If an insurer has acted unfairly through bad faith actions, we’ll find it. We establish whether the insurer has performed a full and fair review of the evidence and records presented in your disability income claim, or if it has denied your claim without considering all evidence.
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