Doctors’ and dentists’ long term disability benefits are denied when the insurance company claims they can still perform the “specialty duties of own occupation.”
Some denial tactics involve “own occupation” disability policies, which are frequently purchased by medical professionals. Within many own occupation policies is the definition of the insured’s specialty duties of own occupation or similar. Often this “specialty own occupation” verbiage is added via a specialty rider at added expense.
Specialty Own Occupation further defines your medical occupation, whereby the insurer is required to recognize your specialty practice as your “occupation.”
Example: your policy defines your occupation as a urology surgeon. If, due to a disabling illness or injury you can no longer do the essential skills and surgical procedures required in your medical specialty – not as a general urologist, but as a urology surgeon – you will be considered totally disabled under your policy. You would expect to receive full disability benefits, even if you continue to work at something else, and regardless of the duties of a more general practice such as assessing patients and performing diagnostic tests.
For this reason, Specialty Own Occ policies are marketed as the chosen insurance, as it should protect doctors, dentists and other highly trained professionals from bad faith claim denials.
But in reality, that does not stop some insurers from disapproving claims. If the insurance carrier can demonstrate a claimant is able perform their own specialty duties while they are engaged in some other gainful occupation, the insurer may be able to use that to deny the doctor’s claim.
How insurers “prove” a doctor or dentist can still perform the specialty duties of his own occupation:
Many insurance providers have claims review and claims handling practices in place designed to deny or reduce Specialty Own Occupation claim benefit amounts, all in a manner that seems legitimate to the unsuspecting claimant.
Tactic #1: Contesting the Disability:
A common argument used by insurance companies is to claim the physician or dentist can still perform the essential duties of his or her specialty, often with evidence supporting the allegation. However, the medical and vocational “proof” gathered by the insurance company may be the result of inordinate actions (or non-actions) such as:
- video surveillance
- their own (often slanted) independent medical exams or vocational exams,
- disregard of the treating physician’s medical opinions
- simply ignoring the specialization as a surgeon, or dentist or other
Tactic #2: Allege the doctor is not really a “specialist”
Using our previous example, the insurer claims the doctor is not really a urology surgeon, but more of a generalist.
They may base their decision on the alleged grounds that, after reviewing the doctor’s appointment books and billing codes, the urologist spent only 6 to 8 hours a week performing vasectomies, removing kidney stones, reconstructive surgery or other procedures.
The insurer is not going to mention the hours spent in post and pre-operative duties, diagnostic exams, test assessments and patient consultations that each surgical procedure required from the urology surgeon.
Tactic #3: Rely on ambiguous disability insurance policy language
Policy language can be an insurance company’s edge. Bear in mind the insurer writes the policy and decides who is disabled. Disability policies are complex, technical contracts involving terminology which can be purposefully evasive or obstructing. This is one reason so many claims are filed with mistakes or insufficient information, or in some way that allows the insurer to deny the claim for reasons beyond the policy’s coverage.
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