Disability Insurance Claim Advice
"Disability Considerations Before and After Surgery"
California Broker
BY ARTHUR L.FRIES - March, 2014
When it comes to the contractual wording of a disability policy, surgery is typically an option for the insured. You hope that the surgery will help reduce or eliminate pain. I'm referring to situations that often involve overuse of hands or arms or significant stress on one's cervical or low back areas.
Those most affected are professionals, such as surgeons, dentists, chiropractors, and optometrists. However, people who work hands on with a computer or are standing on their feet for long periods can face the same medical issues.
The key question then becomes, "Can I help my medical situation in my work life and my personal life? These two areas are often in conflict. And sometimes there are multiple medical symptoms involved that further complicate the issue.
Let's look at several examples: You are a dentist with bi-lateral carpal tunnel syndrome that affects the use of your hands. You have surgery on two different occasions to correct the problem; and you now go back to work. But you are back to performing the same repetitive functions working with dental tools and a high-speed drill. Within a short period, your carpal tunnel symptoms return to your hands and you are back to square one - pain in your hands and difficulty performing on patients effectively and safely. A better way of handling this situation would have been to stop working and go on total disability, assuming your policy would pay you in your occupation. Then wait six or nine months and see how you feel. It may be at that point that you can function reasonably well without having to have any surgery. Or you may have created enough damage to your hands whereby surgery is called for. You may not be able to function any longer in your professional or work life, but you can now function much better in your personal life, such as being able to shave without pain.
Take the case of a surgeon who has an essential tremor in which their hands shake - a condition that is worsened by stress. The surgeon may no longer be able to operate on a patient safely or effectively because they can not tie knots or work with surgical tools. I have yet to see a medication that will resolve the tremors without side effects, leaving the surgeon in the same precarious situation. Some limited surgery options involve the brain, but even with a small risk factor (death), it becomes an option that one must consider very carefully.
If you do not have a disability policy and you face economic devastation, then surgery may be your only alternative. But if you have disability coverage, you can make the choice not to have surgery and collect disability benefits. There is also some limited radiation treatment available for these type of symptoms but you also have risk factors that one must consider carefully.
Another scenario is related to a dual occupation. You are an orthopedic surgeon with any one of a number of medical symptoms (bi-lateral carpal tunnel syndrome, shoulder, cervical, elbow, low back or hips). You have done a lot of procedures and are known for your surgical expertise. You may have surgery in one or more areas and are away from work for a relatively short period. You decide to eliminate the more complicated surgeries and reduce your surgical hours. To make up for some of the loss of income, you perform more office duties and see more patients related to chronic pain issues. You take on more administrative duties. Your goal is to put less strain on your body, but still work in your chosen profession as a physician. You have reduced your overall hours as well. You suffer more than a 20% loss of earnings, which enables you to submit a partial disability claim and collect a percent age of your monthly benefits. After a year or two, you find that even with the reduced hours and less surgical procedures your pain threshold has increased to the point in which you feel you can no longer perform surgical procedures effectively and safely.
Your insurance agent or broker told you that if you could not perform surgery you would be considered totally disabled and could work at another job because you had a broad definition of ''Your Occupation." So you go on total disability and submit a claim. You have one of the older individual disability policies that pays you money for life. Since these policies are no longer available for purchase, you feel good about the decision to purchase disability policies while you were young and at a lower premium with a locked in rate.
After the insurance company(ies) has investigated the claim, they tell you that you have a dual occupation because you are both a surgeon and an office physician. They say you don't do enough procedures to qualify as only a surgeon and that you can continue to work as an office surgeon. Since your income may.have been reduced further, you will only be able to collect a higher percentage of your monthly benefit if you continue to work in your office. If you stop working, the insurance company may say that you don't meet the definition of total disability and will pay you nothing. And if you continue to work, even in a further reduced capacity, you will only be paid to age 65 since partial disability only pays to age 65 -not for lifetime, as was the case with total disability. There is no contractual wording in your policies that says what percentage of your income must come from surgery. Insurance companies make these decisions from an administrative standpoint.
Having surgery will often help with your pain level. But, if your job requires a lot of repetitive movement or you stand on your feet for long periods, you could be reversing the successful aspects of the surgery and be back to the same pain level.
A disability claimant must always understand the language in their disability policy so they know how to act in their future life. The insurance companies' claim processes continue to evolve long into the future. They will look for an opportunity to terminate a claim if your actions are in conflict with your symptoms.
One type of surgery might improve your medical condition to such a point that you are able to go back to work with very little loss of time and have your medical issues resolved. Another type of surgery won't resolve your overall problem, but will improve your condition that you can work part time in your particular occupation. Or you might not be able to work in your occupation, but work in another occupation. Or you might not be able to work at any job, but improve your personal life with respect to your daily living activities.
Because of the variances in disability policy contractual language, what may apply for one claimant may not apply for another. Might the expectations of the insurance company be different from those of your attending physician? Does your attending physician know the differences among a personal disability claim, a workers' compensation claim, and a Social Security disability claim?
If it is personal claim, does that same physician know the differences among an individual policy, a group disability policy with an employer/employee relationship, or a group franchise policy covering members of the same profession on a national basis? Can a surgeon assume that after surgery a patient can go back to work in two months if they had an office job and the same two months if they were a chiropractor?
There are many questions that a claimant must consider before going on a disability claim. Having had surgery merely adds more questions to the equation.
