The Disability Insurance Application Process
A disability insurance claim poses specific challenges for both the disabled dentist or dental professional and for the disability insurance company. Before you start limiting your practice by changing the type of or number of procedures you perform or even stop working, you must understand the five major issues that you will face at the application stage
The timing of your application, the occupational documentation, the medical documentation, and financial documentation are key to getting your disability benefits. Be assured that your claim will be closely scrutinized because of the high-volume exposure to the disability insurance company.
The Five Issues You Need to Know Now
There are five major issues which must be addressed at the outset.
- How does the policy define your occupation and job duties as a dentist or dental professional?
- What is the definition of disability in your policy?
- Is there a residual benefit claim and, if so, what must be proven?
- What is the date of your total disability?
- What proof must be submitted?
You need the assistance of Nancy Cavey, a national dental and dental professional ERISA disability and individual disability attorney so that you understand what you have to prove to get your disability benefit and you don’t make a mistake that will delay or destroy your claim.
- How Does the Policy Define the Term “Occupation” and the Job Duties of a Dentist or Dental Professional? #number1
Get out your disability policy or policies and look at the declaration sheet which outlines what occupation you have insured and then looks at the policy definition of “occupation.”
Write that down. Then check the definition of “occupation” in your other policies. You might be surprised to find there are different definitions of the term “occupation” in each policy you purchased. You’ll have to satisfy the definition of “occupation” for each policy.
So, how does your policy define the term “occupation”?
For example, let’s say you are an orthodontist, and you can no longer perform orthodontal work, but you can still see patients. What benefits are you entitled to collect?
You want to prove that you are totally disabled from performing orthodontal work so that you can collect total disability benefits and still practice dentistry.
On the other hand, the disability insurance company wants to look at your billings and determine what percentage of your practice involves performing orthodontal work and what percentage is seeing patients.
So, what is your dental specialty?
Let’s say you are an oral surgeon. The operative term is “surgeon.”
But that might not be the complete answer! Board certification can be key, and I always want to point out what it takes to become certified. How many hours or surgeries did it take to become certified? Did you have to prove you are competent to perform certain procedures or surgeries?
So, it isn’t as simple as saying that you were an oral surgeon when you became disabled. In fact, different carriers interpret data differently and come to completely different conclusions.
For example, let’s say you are an oral surgeon who does trauma care, on-call surgery and in-office procedures. As a result of a back or knee injury, you can’t stand and operate but can perform other dental procedures.
What was your occupation? Well, Guardian would look at the number of procedures you have done and say that “we won’t pay a total disability claim” while Northwestern Mutual might pay benefits. That’s why it is important to read your policy closely and think this claim through.
What Other Proof Can You Submit of Your Occupation?
I like to supply the disability carrier with other proof of my client’s occupation as I think is appropriate. That can include malpractice applications, malpractice renewal forms, hospital privilege documents, and appointment and surgical calendars. In fact, I hit them with a shock and awe application package that leaves no question about your occupation and the benefits you are owed,
- What is the definition of the term “disability”?
So, now that we know what your occupation is, the next you must prove is the definition of the term “disability” as it applies to you. There is no uniform definition of disability, so, once again, we must get out the policy. Let’s say the policy says that you are disabled if you can’t perform one or more of the substantial and material duties of your occupation as an oral surgeon.
Exactly what are your duties? Which duties are substantial? Which duties are material? Why can’t you perform those duties? You need to establish which of your duties are “substantial” and “material.”
Now that we have established the definition of “disability,” do your medical records support an inability to perform the material and substantial duties of your occupation?
Probably not! Many dentists do not communicate their symptoms or difficulties performing their duties to their physicians for fear of a malpractice claim or losing referral sources.
It is crucial that your medical records are developed to address these issues before you apply for your benefits! I take the time to develop the medical records and correct any defects that might cause the disability carrier to claim that any reduction in your income is related to everything but your disability.
- Is there a residual benefit claim and, if so, what must be proven?
Some policies provide that if you can’t perform some of the material and substantial duties of your occupation while losing at least 80% of your pre-disability wages, you are entitled to be paid residual disability benefits.
This can be the best of worlds for my dental professional clients who still want to work but can’t perform all their duties or who are not yet ready to stop practicing.
However, the carrier will want to establish your pre-disability earnings as a starting point to determine what duties you can’t perform and your lost earnings.
Based on those numbers, the disability insurance carrier wants to say that you haven’t really been an orthodontist when you became disabled and, if the policy allows, pay monthly partial or residual disability benefit based on your non-orthodontal earnings.
This is all about money!
It is not unusual for the disability carrier to ask for your CPT Code data. For example, the policy may say:
“To ensure that we have a complete understanding of your pre-disability work activities and any work activities you have done since the date of disability, please send us a list of CPT codes that reflect your work/billing activity.”
That is a trap! It is not uncommon that your billing activity includes the work of non-dental staff which can color the determination of your occupation. I prefer to get the dentist’s CPT code data and do an analysis of what activities the dentist was doing at the time they became disabled and then cull out the billing activity of any non-dental staff.
I may also have to analyze the units, charges, the total number of units and charges and relative value of units both before and after the date of disability to prove not only the occupation but an inability to perform the material and substantial duties of your occupation.
Let’s start with a simple question
When did your revenue start to go down and why? Write that answer down.
Many times, a dental professional will come to my office and ask about claiming total disability benefits. I stop them and say, let’s look at your numbers and why there was a drop because there is a lot of money on the table we don’t want to walk away from. We will claim both residual and total disability benefits!
Now we know that answer, let’s get the policy out and look at the definition of “residual disability” and “pre-disability” or “before monthly income.” This is the start of the math exercise because that number will be used to determine whether there have been any post-disability earnings that qualify you for residual benefits.
The first step is to determine the period of calculation for determining the pre-disability earnings. It can be the 12 months before the onset of disability, the 24 consecutive months of highest earnings in the 5 years before the onset of disability or the 3 highest years’ earnings out of the 5 years before the onset of disability.
Once we know the pre-disability earnings number, the next step is to determine the amount of loss required to be entitled to monthly residual benefits. In some cases, if your lost income is 80% or more of that pre-disability earnings number, you are entitled to full total disability benefits.
The math continues as we analyze each month’s income to determine the amount of any loss. Once those months are identified, it is back to the medical records to determine if the medical records, as they currently exist, support the claim and, if not, to develop those medical records.
The claimed periods of residual disability must be proven both from a practice and a medical standpoint or the residual claim will fail.
You’ll have to prove this every month in which you claim residual benefits. That will require you to submit Profit and Loss statements and earnings information each and every month.
You’ll also need to be careful with any income attributed to the sale of practice assets, including buildings.
- What is the date of your total disability?
Sometimes it is easy to identify the date of total disability as the date of some catastrophic event, like an auto accident or a heart attack. More often than not, when a dentist or dental professional is eligible for both residual and total disability, we start with the residual claim because they are just not ready to stop practicing cold turkey. More often, the dental professional will, over time, come to a point in time where the professional isn’t making enough money to pay expenses, is asked to leave the practice or just can’t practice anymore.
What is crucial is that you have a plan for gradually easing out of the practice and that you just don’t walk in and say, “I’m done.” If you do that, the carrier is going to wonder why you could practice one day and not the next!
You must have the support of the treating medical providers and they must be willing to complete Attending Physician Statement (APS) forms. If your providers don’t support your claim or aren’t willing to fill out forms, you need to find a new provider before you stop working and claim benefits. It is a simple as that!
It is crucial that all of this be coordinated before you make a mistake that will result in the denial of a claim.
- What Documentation DO I need to Submit to Get My Disability Benefits?
Lots! The disability insurance application seems simple, but it is very deceptive. For example, you will be asked to fill out a form describing your occupation and asked to estimate the percentage of time you spent operating, doing pre or post-op care, at the office seeing patients, or doing managerial tasks. If you answer these questions without careful thought or without looking at your financial documents, you can start a fight about your occupation, your duties and whether you can perform those duties.
That is why I analyze my client’s occupation, gather the documents that prove that occupation and give the carrier little or no reason to challenge my analysis. We want our data to prove your occupation and your production.
This is also crucial as we submit the residual disability claim, which typically, precedes the total disability claim.
You also must produce your medical records. You probably know that medical records rarely tell the story of why the dental professional can’t perform the material and substantial duties of their occupation.
But that isn’t the end of it because, just as crucial, is tying the disability to the loss of income with a vocational rehabilitation report.
I am also prepared to produce, in a shock and awe form, the following:
- Monthly profit and loss statements for up to 5 years before the date of disability, depending on the definition of “before monthly income,” and do so on an ongoing basis;
- Business and Personal Tax returns for up to 5 years before the date of disability, depending on the definition of before monthly income, and do so on an ongoing basis;
- CPT production reports for up to 5 years before the date of disability, depending on the definition of before monthly income, and do so on an ongoing basis;
- A customized spreadsheet that established the before monthly income and the post-disability residual calculations that tells the carrier, to the penny, what they owe.
Your application can make or break your claim from the very beginning. You owe it to yourself to contact Nancy Cavey, before you change the nature of your practice, stop working or apply for benefits.
National Disability Lawyer Offering Help with Every Stage of Your Dental Disability Case
I can assist you, regardless of where you live in the United States, with your decision to make a claim for benefits, file your application, or appeal a wrongful denial or a termination of your benefits.
Call 727-894-3188 for a free initial consultation.
What Every Dentist and Dental Professional Needs to Know About Appealing A Wrongful Denial or Termination of Their Disability Insurance Claim
You bought your disability insurance policy to provide you and your family peace of mind if you became disabled. After all, one in five Americans will become disabled during their working lives.
Has the following happened to you?
- One disability carrier approved your claim while another has denied your claim. Crazy, isn’t, since you submitted the same proof?
- The carrier disagrees with your characterization of your occupation, even though your occupation is crystal clear.
- The carrier refused to pay residual benefits because they can’t figure them out.
- The carrier says, “We don’t think you are disabled anymore.”
- The carrier says that while you were an oral surgeon at the time of your disability, you trained as a dentist and you aren’t disabled because you can be a dentist.
As a national ERISA long term disability and individual disability insurance policy attorney who has represented numerous dentists and dental professionals, I’ve seen these reasons and more as justification for disability insurance carriers to deny claims.
You owe it to yourself to call me at 727-894-3188 for a complimentary consultation TODAY!
The Carrier Has Targeted Certain Medical Conditions for a Claims Denial
I have handled the long-term disability insurance appeals for many dentists or dental professionals with medical conditions such as
- Multiple sclerosis,
- Spinal Conditions, such as herniated discs and fusions,
- Rheumatoid arthritis,
- Cardiological disease,
- Cognitive disorders, including dementia,
- Pain and fatigue associated with autoimmune disease.
- Total knee and hip replacement complications,
- Impairment of the upper extremities, and
- Mental illness.
Yes, disability carriers target claims where the dental professional has a medical condition that is progressive and won’t allow the policyholder to return to work. They don’t want to pay benefits because that isn’t consistent with their business model and profit projections.
What You Need to Do IMMEDIATELY if your ERISA Claim has been Denied or Terminated
You will have only 180 days to file an appeal of an ERISA denied or terminated claim. Don’t delay! If you miss the deadline, you have let your disability carrier rob you and your family of your peace of mind and destroyed your financial security.
Make the call today at 727-894-3188 for a free consultation.