For surgeons, orthopedists, emergency room doctors, ob/gyns and other physicians in physically demanding medical practice areas, the long-term impact of their work can lead to injuries that require the physician to stop practicing medicine. Physical challenges are just part of the picture. The mental and emotional stress of long hours and the responsibility for patient lives can exact a high toll on their mental health as well.

For physicians who become disabled, the economic challenge is substantial. Replacing the physician's six-figure salary that supports an affluent lifestyle is the purpose of a privately owned long-term disability insurance policy. Unfortunately, the high monthly benefit promised in such a policy also sends up a red flag to a claims adjuster when a physician files a claim for long term disability benefits. The same is true for an ERISA disability policy, one issued through an employer, which might be the practice, the hospital or other medical facility if the doctor is an employee.

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Historically, long term disability insurance companies targeted physicians as the perfect customers. Seeking to protect their high income level, the doctors saw the value in investing in private disability insurance policies and it was a fairly easy sell.

At the same time, most doctors continued working well past years when other professionals retired. A general practitioner with a home-based office did not expect to retire until they were well into their 70s or, in some cases, beyond that.

The changes in the health care environment led to a change in the overall practice of medicine. Insurance reimbursements became the norm, small medical practices began to disappear and the general family physician became part of a large medical office with many specialists. Women and men entering medicine today have a different set of expectations of where they will work and what they will earn.

If you are a physician and are concerned that a health condition may lead you to having to file a disability insurance claim, it is very important to be properly prepared. Medical records must document not just what your disability is, but how it precludes you from performing the tasks of your profession. It is important that your role in a practice be defined so the twin issues of "any occupation/own occupation" do not lead to problems for the claim. A surgeon who occasionally checks salary records in a practice does not have the skills of a hospital administrator - but we have seen insurance companies insist that doctors who have a minor involvement in managing a small multi-physician practice have the skill sets to become administrators.

Our experience in representing physicians in disability disputes provides strategic advantages in negotiations and litigation. For example, when a practice does not utilize CPT codes, which is common in high end boutique fee-for-service practices, the insurance company will seek to use this as evidence that the doctor was not working when they claimed to be. Others do not have CPT codes because their record-keeping systems are out of date and don't have the capacity for CPT summaries.

We have also seen instances when investigative field reps present themselves as new patients. They are trying to find out if a doctor is truly practicing when he or she says they are. This is more likely to occur when the claim concerns residual benefits and the physician is working on a limited basis.

These are but two of many strategies used by insurance companies who are challenging physician long term disability insurance benefit claims. Frankel & Newfield has represented doctors in many different specialty areas, each with their own challenges. Put our experience to work for you. Call the office at 877--LTD-CLAIM (877-583-2524) to learn more about how we can help.

Justin C Frankel

Written By:

Justin C. Frankel

Disability Insurance Attorney