Disability Insurance Claim Advice
Disability Claims for Dentists
ADA News, May 16, 2006
By Art Fries
Disability claims for dentists are different. Many individuals may be able to function at a job with cervical, thoracic or lumbar problems, or work in a reduced capacity. However, a dentist can be devastated from a work standpoint if any of the above medical symptoms become chronic and affect performance.
For some dentists, repetitive movements on a daily basis in the performance of their duties puts a strain on parts of their bodies. They reach a point whereby they are holding back with respect to procedures and/or are not effective in the treatment of patients. Pushing one to do a proper procedure can put added stress on injured areas and, over time, can possibly lead to permanent damage. Sometimes, reducing hours of treatment can help, and the dentist can continue working on a part time basis. In other situations, however, it is necessary for the dentist to stop performing clinical duties or go on total disability.
Many individual disability policies that have been purchased by dentists provide partial as well as total disability benefits, often up to age 65 and sometimes for life.
The wording is often occupation specific, meaning that if you can’t perform the substantial and material duties of a dentist but can work in another profession or job, the insurance company will pay you the full amount of the monthly benefit. Your ability to work in your new job must be consistent with the symptoms that disabled you from dentistry.
Although an insurance company may have made certain promises in the way of a disability contract, these broadly worded policies have left a trail of red ink that has caused claim management practices by insurers never envisioned by dentists when the policies were purchased.
In order to control the flow of money from their banks, many insurance companies are using defensive measures that make the claim process more difficult from a claimant’s standpoint. These include a field investigation (personal visit with you), independent medical evaluation (medical exam by doctor paid and selected by insurance company), functional capacity evaluations (tests conducted by physical therapist paid and selected by insurance company), video surveillance and use of forensic certified public accountants.
A field investigation can be unannounced or a specific appointment date can be arranged with claimant. Sometimes the dentist is asked to read and sign a handwritten statement prepared by the field investigator, summarizing the aspects of the claim. This statement should never be signed a the interview, but read carefully by the dentist and returned to the investigator on another day with appropriate corrections made.
With respect to independent medical evaluations, I am seeing these performed with most claims even when the claimant’s attending physician can verify symptoms.
The functional capacity evaluations are also being used more frequently, but typically with those claims related to muscular skeletal (cervical, thoracic, low back) and hand and arms problems. I personally question the ability of an insurance company requiring an FCE based upon policy language that, in many cases, states the insurance company has the right to examine you but often does not say they have the right to test you. An FCE is a test.
Video surveillance is used to determine if the dentist’s medical symptoms are in conflict with the dentist’s personal lifestyle and actions. Athletic and social activities are monitored closely early on, and there can be multiple periods of video surveillance over the life of a claim. A video surveillance team can often even secure access to a guarded/gated community.
With respect to forensic certified public accountants, I am seeing their use more frequently on partial (residual) disability claims to dispute the pre- and post-disability earnings figures provided by the claimant. Sometimes the claimant’s CPA is overly aggressive with respect to the filing of a tax return and deductions are made that are not correct.
The partial disability claim takes longer to agree upon with respect to the percentage the insurance company requires to arrive at the amount of money to be paid. There are times when a compromise will be made to arrive at a figure acceptable to both parties.
In no event should a dentist discuss over the telephone any calculations related to financials (tax returns and so forth). The dentist should request that the insurance company provide in writing any questions it may have, which can then be reviewed by the dentist’s accountant. The CPAs for both sides can then be in discussion (but not the dentist).
How a disability claim is submitted from a paperwork standpoint and how you act in your personal life can determine whether you get paid by the insurance company.
Most attending physicians do not know the difference between a workers’ compensation claim, a Social Security disability claim and your personal or overhead disability policy(s) from a definition standpoint. They physician might be given guidance in understanding the significance of certain questions asked on the claim form.