To file a long term disability claim as a physician, you must be able to prove that your disability prevents you from performing the duties of your occupation. This includes being able to show that you are unable to perform the specialized tasks of your particular field of medicine. If you are unable to do so, your claim may be denied.
If you are a physician who is considering filing for long term disability, it is important to seek the advice of an experienced long term disability attorney to ensure that you have the best chance of success.
Disability from Your Specialty
Many long term disability policies define disability as an inability to perform the duties of your particular medical specialty. For example, if you are a surgeon and suffer from a hand i
njury, your long term disability policy may allow a claim for total disability due to your inability to perform your specialty. However, if you are a family physician who also suffers from the same hand injury, your long term disability policy may not consider you to be totally disabled because you may still be able to perform many of the duties of your occupation, such as seeing patients and writing prescriptions.
Some policies define your specialty explicitly at the time you apply. If this is the case, defining your specialty is easy. But if you are not currently practicing in your specialty, the insurance company may consider you to not be disabled unless you are disabled from the specialty defined in your application.
If your long term disability policy does not define your specialty by name, the long term disability insurance company will determine your specialty by looking at your training, experience, and the type of license you hold. They will also look at whether you are board certified or not. And they may request a history of Current Procedural Terminology or CPT codes to attempt to define your specialty.
It is important to review your long term disability policy carefully to determine how narrowly or broadly disability is defined.
Residual Disability
Similarly, many long term disability policies will allow you to continue to work if your condition only limits your ability to perform certain duties of your occupation, or if your condition limits the amount of time you can work. For example, if you are an OB/GYN and suffer from an injury that prevents you from being able to perform procedures relating to childbirth, but allows you to continue to see patients for gynecological consultations, you
may still be covered by a long term disability policy that provides benefits for residual or partial disability. Or, if you have a condition that limits you to only being able to work as a physician for a limited number of hours each day, you may still be covered by a long term disability policy that provides benefits for residual or partial disability.
Typically, partial disability benefits are calculated as a percentage of the total disability benefit, based on the number of hours you are able to work or as a percentage of the income you were able to earn before your partial disability.
Buy/Sell Policies
Buy/Sell policies or buyout policies are commonly used by physicians who are in private practice, to ensure that the business can continue to operate if one of the partners becomes disabled and is unable to continue working. These types of policies typically provide for the payment of a lump sum benefit to the disabled physician, which can be used to purchase their share of the business from the other partners.
If you have a buy/sell policy in place, it is important to review the terms of the policy carefully to determine whether or not you would be eligible for benefits if you became disabled. Many times, these types of policies have very specific definitions of disability that must be met for benefits to be paid. For example, the policy may require that you be unable to perform the duties of your occupation for a certain period of time, or it may only provide benefits if you are totally disabled and unable to work in any capacity.
Self-Treating
Nearly all long term disability and buy/sell policies require that you be under the care of a
physician with an appropriate specialty in order to be eligible for benefits. And nearly all such policies require that this physician be someone other than yourself.
This means that even if you are a neurologist and you have been diagnosed with Multiple Sclerosis, you must be under the care of a different neurologist to be eligible for benefits. The insurance company will almost certainly deny benefits if you are treating yourself. The insurance company will want to see that you are being treated by a physician on a regular basis and that you are complying with their recommendations in order to be eligible for benefits.
Proof of Income
When filing a long term disability claim, you will be required to prove your prior income. Your long term disability policy will provide benefits that a based on a percentage of your prior i
ncome. Many policies define prior income as your average income over the last 5 years. Or, your prior income may be defined as the average of the highest 2 of the last 5 years of income. If your long term disability policy defines prior income this way, and you have been working for less than 5 years, your prior income will be based on your earnings over the period of time that you have been working. Some policies have much simpler definitions, defining prior income as your income last year.
To prove your prior income, you will need to provide tax returns, W-2 forms, or 1099 forms. If you are self-employed, you will need to provide tax returns and/or profit and loss statements. If you have been working for less than a year, or if your income has changed significantly in the last year, you may need to provide additional documentation to prove your prior income.
Policy Provisions Vary Widely
As you can see, long term disability policies can vary widely in the types of benefits they provide and the conditions that must be met for benefits to be paid. It is important to review your policy carefully and consult with an experienced long term disability attorney to ensure that you understand the provisions of your policy and what you need to do to protect your rights. Other provisions you may want to consider include:
Elimination period or waiting period: An elimination period is the period of time that you must be disabled before the disability insurance company will begin paying benefits. Generally, this period of time is set at 90 or 180 days for employer provided long term disability plans. For long term disability policies bought separately, the elimination period can be as long as a full year.
Benefit percentage: The benefit percentage is the proportion of your prior income that you will receive in benefits. The most common percentage is 60%.
Most long term disability plans provided by employers have a benefit percentage of 60%. In other long term disability policies, the percentage could be as low as 50% or as high as 80%.
Other income benefits or offsets: These provisions will describe the types of income that will reduce your long term disability benefit. For example, receiving Social Security Disability income will reduce your benefit by the amount you receive from the Social Security Administration.
Proving Disability
In addition to the above, you must also prove to the long term disability insurance company that the symptoms of your condition disable you from being able to perform the specific duties of your specialty, or from being a physician generally. The evidence you will need to submit will depend on the type of condition you suffer from. For example, if you have a mental illness, the insurance company will require records from your treating
psychiatrist or primary care physician, as well as reports from psychologists or therapists who have treated you. If you have an orthopedic condition, the insurance company will require records from your treating physician, as well as reports from any specialists who have treated you.
You will also want to supply sufficient testing evidence to the long term disability insurance company. For example, if you have an orthopedic condition, the insurance company will want to see reports of any MRIs or x-rays that have been performed. If you suffer from a condition that affects your brain, the insurance company will want to see reports of any MRIs, CT scans, or EEGs that have been performed.
Functional tests that focus on how your condition causes you to be unable to work are the gold standard for proving disability. Functional tests include functional capacity evaluations and neuropsychological evaluations. You should consider getting at least one of these two types of tests to prove you are no longer able to do your specialty or to be a physician generally.
A functional capacity evaluation is a test that measures your ability to do basic physical tasks. These evaluations will test several areas, including standing, sitting, lifting, gripping, and gross and fine motor skills. Functional capacity evaluations typically involve physical exertion, so they can be used to document symptoms like pain, weakness, range of motion, and fatigue.
A neuropsychological evaluation is a test that measures your cognitive abilities, including things like decision-making, reading, memory, and problem solving. If you have results from these tests that show how your multiple sclerosis has caused you to be unable to work, this will be helpful in proving your long term disability claim.
* * *
The Maddox Firm helps doctors file short term disability claims, long term disability claims, and it helps them appeal denials.