Our client, a well-established and experienced, OB-GYN, who had run a successful medical practice before becoming part of a hospital system, began to experience orthopedic problems that are common to doctors whose practices requires a substantial amount of surgical and clinical procedures. Like many surgeons, she attempted to find ways to minimize discomfort in an effort to be able to continue her surgical duties- from ergonomic interventions to the reduction of and eventual phasing out of medical procedures. However, with time the issues she was experiencing with her hands, elbows and shoulders eventually made it that even gripping of instruments became too painful to bear. As her ability to perform her duties diminished her concern for the well-being and safety of her patients grew. After much discussion with her doctors she determined that in the best interest of her patients that she would cease working. At that time she contacted Attorneys Dell & Schaefer and spoke with Attorney Stephen Jessup.
It is not uncommon for medical professionals to have multiple disability policies – either policies individually purchased through agents, as well as policies provided by employers. Such was the case with our client who had disability policies with Unum and Sun Life. As the laws governing individual disability insurance (IDI) policies and employer provided group (ERISA) policies differ drastically it is very important to understand the differences that occur in both the language of the policies as well as the coverage and protections that are provided by each.
As our client was dealing with two insurance companies it was crucial to make sure that each claim was presented cohesively to both insurance companies. Although it would seem obvious that our client’s medical conditions would prevent her from performing her occupational duties, insurance companies require additional information specific to medical professionals in order to evaluate disability claims. Specifically, when determining one’s occupation it is not enough to simply state what it is, there has to be evidence to support same- in the case of a medical doctor the information necessary to establish the material and substantial duties of the specific medical profession is by way of production codes. When evaluating our client’s claim Attorney Jessup secured her billing codes from her hospital in order to properly present to Sun Life and Unum our client’s actual occupational duties, with specific attention to her surgical duty requirements. Had either carrier determined that there was insufficient evidence to support our client’s assertion that the majority of her duties were surgical in nature there would have stood a good chance that Unum or Sun Life could have argued that despite her medical conditions she would still be able to practice medicine.
As our client worked for an employer at the time of her disability, there was less of an emphasis placed on financial records from our client- such as tax returns and/or profit and loss statements. However, it should be noted to any doctor who may be reading this article that if you do own your own practice your insurance carrier will also require a significant amount of financial information in conjunction with billing codes in order to determine disability in light of your policy provisions. Although our client did not have to provide extensive financial information, her claim still required additional analysis be provided to Unum and Sun Life to establish how she was compensated to ensure her benefits would be paid properly.
Approval of Benefits
Knowing what information would be required by Unum to evaluate her claim under the IDI policy and what would be required by Sun Life in order to evaluate her claim under her employer’s policy allowed Attorney Jessup to fast track our client’s applications for benefits. Within three months of filing her claims with Unum and Sun Life both carriers advised our office that they were approving our client’s claims. Despite a quick review process, during the course of the claim review both Unum and Sun Life required lengthy field interviews with our client along with requests for clarification and/or additional information. Throughout the entire process Attorney Jessup acted as the contact point for both carriers and prepared our client for each step along the way. The groundwork set forth with our client that occurred prior to filing her applications insured that all information be presented was cohesive and that ensured that any potential roadblocks to an award of benefits would be minimized or removed completely.
If you are a medical professional thinking about filing a claim it is crucial to know how your disability insurance policy(ies) work. Even in instances where all coverage is through the same insurance company, each plan can have different language, which affects the outlook of a disability claim. Please feel free to contact our office for a free consultation and review of your disability policy.