It’s important to know the type of policy you have and to be aware that not all policies are created equal.
If you’re a practicing dentist, there’s a high likelihood that you’ll have to file a disability claim at some point in your career.[i] Three out of four dentists suffer from musculoskeletal disorders that affect their ability to practice, and studies estimate that the percentage of dental professionals suffering from general pain in the back, neck, shoulder, or arm is as high as 68%.[ii]

This is not surprising, given the unique demands of the profession (i.e. holding prolonged static postures, constant forward bending, repeated rotation of the head, neck, and trunk to one side, repetitive motions, mechanical stress, and working with vibrating instruments). Over time, these demands can wear down your body and make you more susceptible to degenerative, disabling conditions like carpal tunnel syndrome, arthritis, degenerative disc disease, radiculopathy, spondylosis, and stenosis.

What does this mean for you as a dentist?

It means that you should seriously consider purchasing disability insurance if you do not have it already. And if you do have a policy, it means that you should actually read it, become familiar with the terms of your policy and your monthly benefit amount, and evaluate whether you have sufficient coverage or need to take steps to modify or increase your coverage. If you are experiencing hand/arm/neck/back pain and think you may have to file a claim in the future, you should also start learning about how the disability claims process works now, so you don’t find yourself unprepared when it comes time to file a claim.

What to Look for When Reviewing Your Policy

When reviewing your policy, we recommend that you consider (at a minimum):

  • What type of policy you have;
  • Whether you have enough coverage; and
  • What options are available for increasing your coverage, if you are underinsured.

What Type of Coverage Do You Have?

To start off, it’s important to know the type of policy you have and to be aware that not all policies are created equal. Most dentists obtain disability policies from three main sources—their employer, a dental association or other group they belong to, or individually, through a private insurance company.

Employer-Sponsored Disability Insurance: These policies are often the least expensive option, and we are seeing dentists with these types of policies more often now, as corporate dentistry becomes more prevalent. Under these policies, employees are typically provided benefits based on a percentage of their base salary, as part of their employer’s overall benefits package. These policies are also governed by the Employee Retirement Income Security Act of 1974 (ERISA). Under ERISA, policyholders are deprived of rights they would normally have under state law, including the right to trial by jury and the possibility of punitive damages when the insurer has acted unreasonably or maliciously. Additionally, employer sponsored plans are generally not transferable (i.e. you lose coverage if you stop working for that particular employer), which can make them a less attractive option for dentists, who may end up having several different employers as they move through their careers.

Group Disability Insurance: Group policies are made available to participants of organizations, such as the American Dental Association (ADA) or similar groups. Insureds typically receive a monthly benefit that is calculated as a certain percentage of their base salary (often with a cap on the maximum amount of benefits available under the policy). With group disability insurance, you are covered by the policy, but the group is the actual the owner of the policy itself. This means that the group can periodically renegotiate the terms of the policy and your coverage can change without your consent or approval.

Individual Disability Insurance: Individuals purchase this kind of policy directly from the carrier and usually receive coverage at a specified amount (e.g. $5,000 a month), rather than a percentage of their salary. In most instances, the more individual coverage a dentist has the better. This is because individual insurance is governed by state law, which is generally more favorable to policyholders than ERISA.

Generally speaking, individual policies or group policies are the best choice for most dentists, as they are governed by more favorable law. However, each policy has its pros and cons. Disability insurance policies (particularly newer, post-2000 policies) are complex documents and, while policy “data sheets” and marketing materials can provide helpful summarizes of key benefits, it’s important to keep in mind that these are just summaries. Most of the time, the focus of these sorts of documents is on the benefits of the policy, and they don’t give equal air time to the restrictions and limitations that are contained in the fine print of the policy itself.

All too often, we consult with dentists who did not carefully review their individual policy and are not aware that, for example, their policies contain a “no work” provision that precludes them from receiving total disability benefits if they are working in any capacity (even if they’re not working in dentistry). Applying for an individual policy is just the first step—you also have to take the time to read and carefully review the policy you are purchasing, and make sure that it is line with what you think you are getting.

Do You Have Enough Coverage?

Many dentists purchase their first disability policy around the time they graduate from dental school or shortly after establishing their practice, file the policy away, and don’t think about it again until the unexpected happens. Then, when it is time to file a claim, they realize their financial needs and obligations have changed dramatically, and that their monthly disability benefit is significantly less than the monthly income they have grown accustomed to. For instance, if you are a dentist earning $20,000 a month and need to file a claim, you don’t want to have to end up relying on a disability policy that only pays $4,000 a month as your primary source of income.

While insurance companies’ underwriting requirements are typically structured to prevent you from collecting a total benefit amount that is equivalent to (or exceeds) your monthly income, you should seriously consider maxing out your benefit amount, if you can afford it.

How Can You Increase Your Disability Coverage?

Some companies offer “automatic increase” riders, which will periodically automatically increase your benefit amount over time, as long as you agree to pay a higher premium with each benefit increase.

Another option is a “future increase option” rider. This rider allows you to purchase additional coverage without changing the terms of your existing policy. While you will likely be required to disclose your financial information to verify that you qualify for the increase, some riders allow you to avoid going through additional medical underwriting when exercising an increase option. This is significant because, as you grow older, you will likely have new medical conditions or diagnoses that you did not have when you first purchased the policy that may otherwise be excluded if you were applying for a new, separate policy.

Typically, these methods of increasing your benefit amount will only be available during discrete time periods set forth in the policy (usually around the policy’s anniversary date), so it’s important to read your policy carefully to make sure you don’t miss out on the opportunity to take advantage of an increase option.

If your policy does not have increase options and you’ve outgrown the monthly benefit amount of your existing policy, you can also purchase another policy to increase the total coverage you would receive if you filed a claim. However, if you’re going to be purchasing a new policy, keep in mind that you must purchase a policy that complements—rather than cancels out—your existing coverage.

For example, as noted above, some policies contain provisions stating that a claimant cannot collect total disability benefits if he or she is working in another profession (a “no-work” provision). At the same time, other policies require the policyholder to work in some other capacity in order to collect total disability benefits (a “work” provision). Thus, if you were to purchase a new policy with a “work” provision, and your old policy had a “no work” provision, one of the policies would be rendered useless (because it would be impossible to collect total disability benefits under both policies).

What Can You Expect When Filing a Disability Claim?

After ensuring that you have sufficient coverage, the next step is learning about how the claims process works. So what should you expect if you end up needing to file a disability claim?

Many dentists believe that they’ll simply submit their claim, have their doctor sign a form, and start receiving their monthly benefit checks. However, in reality, the disability claim process is much more involved than that.

While each claim is different, insurance companies will typically:

  • Speak with your treatment providers, family, friends, and co-workers about your condition. At the outset of the claim, the insurance company will have you sign authorizations that grant the insurance company sweeping authority to speak directly with a host of individuals (e.g. any physician you have ever been treated by, pharmacies, benefit plan administrators, insurance agents, financial institutions, the Social Security Administration, family, friends, co-workers and employees, among others).
  • Request a wide range of personal information. Most authorizations also allow the disability insurer to request virtually any information not otherwise barred by law–not just medical records. The information can include medical records, tests, or consultations, prescription history, mental health records, HIV/AIDS treatment information, records for any substance abuse treatment, court records, occupational data, employment history, driving history, financial statements, and your earning history.
  • Schedule face-to-face interviews with you. Many insurers seek to interview you in your home, so that they can view your surroundings to see if they can find discrepancies in the claim, or learn more about you so that it is easier for them to conduct surveillance. These interviews can be stressful if you’ve never experienced them before, and it can be difficult to discuss your medical conditions and the facts surrounding them with a complete stranger.
  • Order an In-Person Exam. The insurance company may claim that the exam is used to verify a disability; however, insurers also use these exams as a means to criticize your provider’s course of treatment, or dispute your provider’s conclusions and diagnoses. Most disability policies also provide that refusal to participate in an exam allows the insurance company to deny a claim or terminate benefits.
  • Use a private investigator to conduct surveillance. The insurance company may employ a private investigator to conduct photo, video and/or online surveillance, in an attempt to find discrepancies in your claim, or evidence of “malingering.” This can pose a particular challenge for dentist claims, as oftentimes a dentist or physician’s symptoms may be significantly alleviated once he or she steps away from the demands of practicing.

Do I Need an Attorney to File a Disability Claim?

Disability claim investigations can be very invasive, particularly if you have a high-paying policy and there is significant liability on the line for the insurance company. In many instances, the companies stand to save millions if they are able to successfully deny or terminate a dentist’s claim. If you have never experienced the claim process before, it can be hard to tell whether your insurer is taking things too far.

There are also several important decisions that need to be made during this transition period (i.e. whether to sell your practice, whether you should keep your license active or let is lapse, whether your policies allow you to pursue other employment opportunities, etc.). And if you have a slowly progressive condition, like degenerative disc disease, it can be difficult to know when your symptoms and limitations are serious enough to start considering filing a disability claim.

Generally speaking, your options will become more and more limited as your condition progresses. For example, you may hurt a patient and have to deal with malpractice and/or licensing issues. Or your practice may start to lose value as you reduce your hours or stop doing certain procedures and then, when you decide that you want to sell your practice, no one is interested. Additionally, working less hours and/or limiting the work you do can also modify your occupational definition under your policy, and make it harder to collect.

If you don’t speak with an attorney at the outset of your claim, you likely will not have a full picture of what actions can negatively affect your claim. And if you wait until your claim is denied, or your benefits are terminated to talk with an attorney, at that point, your claim may no longer be salvageable. And even if you are able to get the denial reversed, this typically requires litigation (which is costly) and several years of going without benefits before everything is worked out and settled.

It is much better to take the time to become informed about the process, have a plan for your transition out of practice, and do things correctly the first time around. Because of this, we recommend that dentists, at a minimum, consult with an experienced disability attorney as early as possible in the process, so that they understand the potential challenges associated with their claims and can make an informed decision regarding how to proceed.


Credit –

Derek Funk, Esq. and Peter Brown
PUBLISHED: Tuesday, August 28, 2018
https://www.dmdtoday.com/news/dentist-disability-insurance-guide
Derek R. Funk, Esq. is an associate attorney practicing at Comitz | Beethe. Mr. Funk primarily practices in the areas of disability insurance and insurance bad faith litigation and advises dentists and other professionals throughout all stages of the disability claims process.

DISCLAIMER
The information in this article has been prepared for informational purposes only and does not constitute legal advice. Anyone reading this article should not act on any information contained therein without seeking professional counsel from an attorneyThe author and publisher shall not be responsible for any damages resulting from any error, inaccuracy or omission contained in this publication.

[i] According to the ADA’s statistics, one in four dentists will become disabled long enough to collect benefits before retirement. ADA, Disability Income Protection Insurance Planhttps://www.insurance.ada.org/ada-insurance-plans/disability-insurance.aspx (accessed July 26, 2018).
[ii] H.S. Bedi, Ninad Joshirao Moon, et al., Evaluation of Musculoskeletal Disorders in Dentists and Application of DMAIC Technique to Improve the Ergonomics at Dental Clinics and Meta-Analysis of Literature, J. Clin. Diagn. Res., Jun 1, 2015, at 1.