|Publication:||Name: The Forensic Examiner Publisher: American College of Forensic Examiners Audience: Professional Format: Magazine/Journal Subject: Health; Law; Science and technology Copyright: COPYRIGHT 2011 American College of Forensic Examiners ISSN: 1084-5569|
|Issue:||Date: Spring, 2011 Source Volume: 20 Source Issue: 1|
|Topic:||Computer Subject: Insurance industry|
|Product:||Product Code: 6323000 Income Loss Insurance; 9105313 Special Disability Insurance NAICS Code: 524114 Direct Health and Medical Insurance Carriers; 92313 Administration of Human Resource Programs (except Education, Public Health, and Veterans' Affairs Programs) SIC Code: 6321 Accident and health insurance|
Individual disability policies often provide both a total and a
partial (residual or proportionate) definition of disability. As a
result, things can get tricky at claim time. For instance, an OB/GYN
physician might be considered totally disabled if he can no longer
perform surgery or deliver babies, but if he can still work in his
office, this might not be defined as a total disability.
For example, the insurance company may interpret the above claim as one in which the insured is merely partially disabled because the insured continues to perform duties in the office and earn money. This is a very complicated area, and court decisions have varied by state and local jurisdictions. Variations in policy language as to what constitutes total disability--or what constitutes "substantial and material"--can also affect decisions. A "specialty letter" that explicitly recognizes an insured's occupation as a narrow specialty (such as an invasive cardiologist), WHEN the policy was purchased--and how the policy was marketed by the broker/agent/insurance company or how the claim was submitted from a paperwork standpoint--can also have an influence on how the insurance company interprets the claim.
One example of the "dual occupation" dilemma would be the case of an orthopedic surgeon whose duties include surgery, emergency surgery, "on calls" and an office practice seeing patients related to orthopedics. Let's say that, because of past heart attacks, he reduces his hours and stops performing surgery and taking emergency calls. His reduced work schedule consists solely of clinical and non-surgery orthopedics. Should the insurance company consider this a total or a partial disability claim?
The answer is that it could go either way, although there is a good deal of case law that might substantiate total disability. The insurance company will take into consideration how much surgery and on calls the orthopedic surgeon performed prior to the disability (by obtaining medical billing code numbers, etc.) and look at the pre-disability earnings compared to the post-disability earnings in various areas.
SINCE 1995, ADVICE PROVIDED ON 650+ DISABILITY CLAIMS WITH BENEFITS SECURED FOR CLAIMANTS OVER ONE BILLION DOLLARS
To further complicate matters, let's assume this claimant taught once a week at a local university for a full day and was paid a salary for his efforts. Could this change the way the definition of disability was considered and determined? How old the claimant is and whether the benefit is paid to age 65 or life can also influence the decision.
In the above example, if the orthopedic surgeon was age 58 with a lifetime benefit (if disabled prior to age 60), the insurance company may very well want to "push" the insured into a partial claim in order to only pay benefits to age 65 rather than for life (which could be for another 15-20 years or more).
If you are beginning to think a disability can be complicated, let's go even a step further. You are a practicing surgeon, but you were also involved with doing "Medical Reviews" and "Expert Witness Work." Maybe you also do a number of IME's (Independent/Qualified Medical Evaluations). If you cannot continue to do surgery but you can continue to do expert witness work, IME's and QME's, would that constitute a total disability? What if your broker/agent told you that you were covered in "your occupation" ... would you be covered? Does the amount of work you performed other than surgery have a bearing on how the insurance company will interpret your claim? Are there any guidelines established that tell you what is permissible? Might an insurance company decide that you have 3 occupations? These constitute the "grey" area related to disability claims, and often there are no clear answers. Nevertheless how you complete the claim forms and how your attending physician completes the claim forms, as well as how you react to the various weapons at an insurance company's disposal, can determine the outcome of your claim.
When there is a need for accounting advice, consult with your CPA. When there is a need for a legal opinion, consult with your attorney. When there is a need for advice related to policy language and how an insurance company interprets your disability claim, consult with a DISABILITY CLAIM CONSULTANT.
Disability Claim Consultant
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