What is Complete Disablity?

Knowing the difference between “partially” and “totally disabled” can save you millions.

Why does it matter whether you are considered totally or partially disabled by your disability insurance carrier? Most disability insurance policies provide that a person with a partial disability will be paid through age 65, while someone on total disability benefits will be paid for the duration of his or her life.

Partial disability benefits are based on the percentage of earned income lost. Unlike total disability benefits, if a person does not suffer a loss of earned income, benefits are not paid.

If a person’s disability insurance carrier buys out his or her contract resulting in a lump sum settlement in lieu of periodic payments, the person would be more apt to surrender the contract for less money if his or her disability were deemed partial rather than total.

Insurance companies save themselves hundreds of millions of dollars each year by paying out partial rather than total disability benefits to their claimants. This is what happened to my client, Dr. Brown.

Fourteen years ago – shortly after starting his dental practice – Dr. Brown bought an insurance policy to protect his income in case he suffered an illness or injury that prevented him from completely or partially ­working. During the years, Dr. Brown’s practice grew substantially, and so did his annual income. As such, Dr. Brown’s insurance carrier made several offers to increase his monthly disability benefit in case of total disability. Each time, Dr. Brown gladly accepted the increase in premium payments for the added protection.

Dr. Brown’s practice consisted mainly of bridge and crown work, root canals, extractions, and general dentistry. Four years ago, Dr. Brown began to experience stiffness and pain that radiated through his right arm and shoulder. At first, he dismissed the pain as overuse and applied home remedies. Nevertheless, the pain became more severe, more frequent, and lingered longer. Dr. Brown sought treatment from a rheumatologist and subsequently was diagnosed with osteoarthritis. He continued to treat patients. His pain, now excruciating after two hours of use, forced him to change his practice significantly. He had to forego bridge and crown work, root canals, and more difficult extractions.

After almost a year of cutting back, Dr. Brown read the disability income policy he bought years earlier. His policy provided:

Dr. Brown applied for disability benefits. Shortly after he mailed his application, he received a call from his carrier. The claims analyst asked many questions regarding his condition and his continued treatment of patients. The analyst requested additional documentation and said that the carrier’s investigation might take several weeks. Five and a half weeks later, the insurance carrier sent Dr. Brown a correspondence that read, “We conducted a thorough investigation into your claim for disability income benefits and we are pleased to inform you that you are eligible to receive benefits under the terms of your disability income contract. As you are still working in your profession, you will receive partial disability benefits as long as you remain partially disabled and continue to suffer at least a 20 percent loss of earned monthly income.”

The news pleased Dr. Brown. Many of his colleagues had received negative responses from their insurance carriers when attempting to collect their disability income policies.

Dr. Brown had to provide his carrier with monthly profit-and-loss statements. For several months he received no benefits because he did not sustain at least a 20 percent loss of earned income. Dr. Brown hired another dentist to perform procedures that he could no longer perform safely. After paying the salary of the replacement dentist, Dr. Brown’s practice still made a substantial profit. This resulted in fewer months in which Dr. Brown was eligible to collect his disability income benefit. After two years, Dr. Brown’s carrier approached him to request a buyout of his disability income contract. The carrier offered him $100,000 for the surrender of his contract. Dr. Brown found this fair because most months he collected little or nothing in partial disability benefits. Nevertheless, before signing the agreement, Dr. Brown wanted an attorney to review the buyout agreement and advise him of his rights. Dr. Brown contacted my office.

After speaking with Dr. Brown and reading his contract, I realized the offer was unreasonably low and that Dr. Brown was actually totally rather than partially disabled and had been eligible to receive his full benefit for the two years prior and possibly for the rest of his life. When I explained my concerns to Dr. Brown, he said, “I am still working; I’m not totally disabled.”

Like so many others, Dr. Brown thought “total disability” meant the complete inability to engage in his occupation. This erroneous assumption was given credence by the insurance carrier’s simple statement, “As you are still working in your profession you will receive partial disability benefits… “. It was perpetuated by two years of similar statements by the carrier and eventually a seemingly gracious offer to buy out an all but useless policy for $100,000.

As many disability policies provide that the inability to perform one substantial and material duty renders a claimant partially disabled, many claimants infer that total disability must be the inability to perform every single duty of the claimant’s occupation. Many people do not know that often a claimant’s disability may render him both totally and partially disabled under the terms of the disability insurance contract. In most states, ambiguous contract language is decided in favor of the insured. If there are two reasonable interpretations of the same provision, it is considered an ambiguous term. Many claims analysts continue to misread these provisions and determine that the claimant is partially rather than totally disabled, as he is still working in his dental practice. Claimants unversed in contract interpretation will often look to the writer of the contract, in this case, their insurance carrier, for clarification. When they are informed that because they continue to work they are partially rather than totally disabled, this interpretation seems reasonable to many claimants. The conflict is obvious.

As I explained to Dr. Brown, under the terms of his contract, total disability means the inability to perform the “substantial and material” duties of his occupation as they were just prior to his illness. Dr. Brown’s substantial and material duties prior to his disability consisted of root canals, extractions, bride and crown work, consultations, and many cosmetic procedures. Dr. Brown’s post-disability duties consisted mainly of some simple procedures and consultations. He was unable to perform the substantial and material duties of his occupation and thus was totally disabled under the terms of his contract. Most significantly, Dr. Brown had been paying premiums for more than a decade for this protection.

After our initial consultation, Dr. Brown turned down his carrier’s offer to buy out his contract and retained our firm to assert his rights to total disability income benefits under the terms of his contract. I was able to secure Dr. Brown’s total disability benefits, his back benefits totaling almost $200,000, interest on his back benefits, and attorneys’ fees. Ultimately, we negotiated a buyout of Dr. Brown’s contract, one well in excess of the meager $100,000 the carrier first offered to settle his claim.

Contract interpretation might be difficult for the layman. Insurance claims examiners can make mistakes in interpreting the provisions of your disability insurance contract. Relying on the wrong interpretation could result in the loss of hundreds of thousands of dollars over a claimant’s lifetime. Always seek advice prior to filing a claim, appealing an erroneous decision, or accepting an offer to buy out your disability insurance contract.

Questions About Hiring Us

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Dell & Schaefer Client Reviews   *****

Leza A.

Extremely professional, knowledgeable, immediately responsive to all my calls and emails, always left comforted that my case is being given all that can be done to accomplish the best results after talking/emailing with Rachel Alters (my attorney) and her team. It has been the best decision I have ever made when I needed the best to help me at such a vulnerable time in my life of having to deal with being so ill and then the realization of the loss of my career that I loved so much, that I had given my all to, and was so successful at.

I can’t thank Dell & Schaefer (Rachel Alters & Team) enough for giving their all for me (my case).

***** 5 stars based on 202 reviews

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