Filing a Claim for Disability Benefits – What You Can Expect

Don’t expect the same response from the disability insurance company that you expect to receive from homeowners or auto insurance companies. How your claim is prepared in advance and what you do if it’s delayed or denied could make all the difference for you and your family.

Editor's Note: This is the first in a series of four articles prepared by Jason Newfield and Justin Frankel of Frankel & Newfield law firm on disability claims and what the practicing dentist can expect when filing a claim. Their goal is to educate dentists, so they are better prepared to file and address the outcomes of their disability claims.

Recognizing the importance of having disability insurance is an important part of any dentist’s financial well-being. The body-mechanics of dentistry — exerting a strong amount of force using the hands, arms, shoulders and back, combined with repetitive motions, often with vibrating instruments over extended periods of time – often leads to musculoskeletal injuries that can make practicing dentistry difficult and often, impossible, due both to pain and the functional issues attendant to the condition.

Most dentists don’t think of their profession as a highly physical one, but the number of dentists we represent in our disability insurance law firm upends that idea. The prevalence of disability for dentists is one of the highest among all white-collar professions. Insurance companies are often wary of claims by dentists due to how many they see filed.

First Step: Preparing to File a Disability Claim

Understand that the disability policy is essentially a contract between the insured and the insurance company. The terms and provisions in the policy define the entire process, including the restrictions and limitations that are commonly faced and the respective rights and obligations of the parties to the contract.

The first step in preparing to file a claim is to review the terms of the policy. We routinely find issues that dentists are not aware of, and even the straightforward matters can become problematic.

The issues that come to light during a policy review include:

• Elimination period — how long do you have to wait until benefits will be paid?
• Definition of disability — these vary widely from policy to policy. Some definitions are more favorable than others, and some are overly restrictive.
• Partial disability terms — could you work part time or in a related capacity and still collect benefits?
• Insurance company’s rights to contest the claim — and proof of loss – what is required to prove the claim.
• Requirements for medical examinations — includes IMEs and FCEs – examinations or evaluations.

After a thorough review, you should have a better understanding what the insurance company wants to see as for the proof of disability, before it will consider issuing a check to its insured.

Receiving a diagnosis, no matter how dire, is not enough to entitle one to receive benefits.

The insurance company needs to appreciate that you are unable to perform the tasks that are a part of your occupation. Often, it is considered the “material” or “important” duties of the occupation. Our office works closely with treating physicians to be sure that the medical records reflect this information, and the appropriate restrictions and limitations in functionality which impair one from practicing.

Here’s the fine point: you took out disability insurance to insure your income as a dentist. If you own your own practice and you are actively engaged in the administrative functions of the office, the insurer will likely seek to argue that while you cannot perform the tasks of dentistry, you can still do certain administrative duties. Or, the insurance company will claim that you can still evaluate patients and create a treatment plan, even if you are not performing the actual dental services.

They may claim that these duties are material, and that diagnosing patients is also material, as part of an attempt to create a claim for partial disability, rather than full disability. If you own the dental practice or have partners, the situation may be more compromised.

Once a claim becomes partial versus total, the door will be open to the insurance company’s need to perform a financial analysis of all income, and a loss of income will need to be demonstrated. The maximum benefit period could also be impacted if a partial disability claim is established.

The review of the disability insurance policy is not a cursory matter, and an experienced disability insurance attorney will provide valuable insights.

Next Step: A Conversation with Your Treating Physician

Unless your doctor has experience with disability claims, it is highly unlikely that he or she understands the importance of properly prepared medical records when pursuing a disability insurance claim. The insurer will be reviewing medical records, and they may contact the doctor directly or speak with support staff in the doctor’s office. If the records are not properly prepared with an eye to a disability claim, providing support rather than simply a diagnosis, or if a casual comment is made to the effect that the dentist is not really disabled, the claim could be stopped dead in its tracks at this point.

Our firm devotes a good deal of time to working with treating physicians. We educate them about the importance of their notes in the records, the need to include the limitations that the disability has created for the dentist and the definitions in the terms of the policies that are critical to the claim’s success.

Many treating physicians think that “disability” refers to someone who is bedridden or in a wheelchair. They do not understand the nuances, nor should they: it’s not their policy and it’s not their claim. But the physician plays a critical role, providing objective support for the claim and supporting the claim with objective diagnostic tests and when necessary, documented clinical findings.

What is the Claimant Required to Do?

Today the number of potential pitfalls for a disability claim has increased dramatically. In the past, the claimant would receive a folder or kit with forms to complete. Those forms were spring-loaded and were designed to elicit information that might negatively impact a claim. Unsuspecting claimants who did not recognize this were doomed to make mistakes that would lead their own claim to disaster.

Now, you can go online and provide information that leads to a denial or a request for more information faster than ever before. The convenient portals now available to claimants make the application process seem like any other information they post on the web.

What they don’t tell you on the form is what will happen to the information.

It must be understood that any information provided to the insurance company, from doctor’s charts to office notes to online forms or old school hard copy forms, are essentially building the foundation for the insurance company to deny a claim.

If the claim is being made on a policy that the dentist gets through work, versus a privately purchased policy, the documents in the “claim file” are the ONLY documents that can be reviewed during a Federal Court review of an administrative appeal. If the disability claim is an employee benefit, it is governed by a set of rules known as ERISA (Employee Retirement Income Security Act of 1974, a federal law that was originally designed to protect employees).

Under this law, the policyowner does not get a jury trial, but any denials or challenges to the claim must be decided through an administrative hearing, prior to even getting the ability to sue the insurance company. In litigation, generally the only documents that can be reviewed to make the decision are in the claims record — the file of materials gathered by the disability insurance company.

In our next article, we’ll examine what happens once your claim is filed.

Jason Newfield and Justin Frankel are the founding partners of Frankel & Newfield, a law firm focusing on long term disability insurance issues on behalf of claimants. Both have attained AV Preeminent ratings from Martindale-Hubbell® and have been selected for inclusion in the Metro New York Super Lawyers. The practice represents many dentists, orthodontists, periodontists and other medical professionals.

RELATED: For more on insurance and disability claims:

• Not All Disability Policies Are Created Equal
• Is Your Dental Practice Prepared for an Insurance Audit?