Long Term Disability (LTD) for Doctors and Professionals

What to Do When Your Long-Term Disability Claim is Denied

Long-term disability (LTD) insurance is meant to provide income replacement for a specified period if you become unable to work due to injury or illness. These policies cover millions of business executives and licensed professionals across a number of fields. Doctors, in particular, can benefit from LTD coverage, and, indeed, millions of physicians, surgeons and medical doctors in the U.S. count on this coverage should they become disabled from working.

Sadly, policyholders who submit claims for LTD benefits are rejected by their insurers more than 50% of the time. Despite being learned professionals and experts in their field, physicians and surgeons are not experts in the field of insurance law and often don’t know how to deal with an insurance denial. At Gianelli & Morris, insurance law is all we do. If your claim for LTD benefits was denied, our insurance law experts will take on the job of getting you the full value of your claim sooner rather than later. Learn more about LTD denial issues below, and call Gianelli & Morris if you’re a California doctor whose LTD claim was turned down.

What LTD Does/Why You Need It

Long-term disability insurance provides replacement income if you become disabled and can’t perform the duties of your profession. The exact terms depend on your specific policy, but LTD policies, in general, provide up to 60% of income and cover illness, disease, mental nervous disorder, accident or injury. Payment of benefits might turn, in part, on whether the disability is considered total, partial or presumptive:

• Total disability means you can’t work presently, but you might recover from the disability and be able to return to work.

• Partial disability means you are able to work but not at your regular capacity. The insurer might pay a percentage of benefits in this instance, depending on the policy.

• Presumptive disability means that the condition is presumed to be permanent, and you should receive benefits for the entire payment period. Loss of sight, hearing, speech or the loss of two limbs are common types of presumptive disability.

Own Occupation Versus Any Occupation LTD Insurance

One of the most important facts to know about your LTD policy is whether it is an “Own Occupation” or an “Any Occupation” policy. “Own Occupation” means you cannot perform the duties of your profession: if you are a surgeon, you cannot operate, for instance. In a true Own Occupation policy, you could work elsewhere or in some other capacity and still receive benefits. In contrast, if the policy is “Any Occupation,” then the insurer can refuse to pay benefits so long as you can work in any occupation that you are fit for.

The precise language in your policy is controlling. For instance, you may have an Own Occupation policy that only pays benefits if you cannot work in any occupation that you are reasonably suited for, given your education, training and experience. This might not be what you thought you were getting when the agent sold you an Own Occupation policy. Some Own Occupation policies will also pay a transitional benefit if you are working in another occupation, although the benefit will be offset by the money you earn. Other Own Occupation policies will only pay benefits if you are not engaged to work in any other occupation. In other words, you get benefits even if you can take another job, so long as you don’t actually do so. Still other policies are hybrids, switching from Own Occupation to Any Occupation after a period of time set forth in the policy.

Doctors, in particular, run into difficulties getting their LTD claims approved because of the nature of their profession. If you have an Own Occupation policy, the definition of disability should be specific to your specialty. Insurers often lack the understanding of your specialty and will misconstrue it. They’ll confuse your ability to practice in some fashion with your ability to perform in your specialty area.

An Any Occupation LTD policy is relatively inexpensive compared to an Own Occupation policy because you are less likely to be so totally disabled you can’t work at all. An Own Occupation policy is much more valuable to you as a surgeon or other skilled professional, but you’ll likely need help getting the benefit of your policy and convincing the insurer you qualify for benefits.

Why LTD Claims Get Denied (or Delayed and Delayed)

LTD claims are notorious not just for their high rate of denials, but also for the interminable delays policyholders must go through to get their benefits or keep them from being cut short. Here are some of the main ways insurance companies drag out the approval process and why they eventually deny claims.

• The insurance company maintains they are still reviewing the medical records and need more time to decide.

• The insurance company is checking to see if you had any pre-existing conditions that were undisclosed in the application process.

• The insurance company looks for any incomplete or inaccurate information on your initial application or any monthly claimant statement.

• The insurance company claims it is not getting the communication it needs from the physician who is treating you, e.g., doctors are not sending over medical records, not returning calls, or not properly submitting the attending physician statement.

• The insurance company asks for documentation every month, and every month their request is for something new and different. Eventually, they’ll find some error, inconsistency, or failure to provide requested documentation they can use as a basis to deny your claim.

Why You Need a Lawyer for an LTD Claim

You may have already known you needed LTD insurance, and perhaps you’ve been covered for years. If you ever have to make a claim, you’ll find that having a lawyer on your side can prove invaluable to receiving benefits in an industry where more than half of all claims are rejected. An experienced long-term disability insurance attorney can help you in many ways. For instance:

• Choosing the correct date of disability is a critical factor that must be appropriately considered as early as the initial claim application.

• An expert LTD insurance lawyer knows how to establish your eligibility for benefits under an Own Occupation LTD policy.

• Your lawyer can work with your treating physician to make sure they send the right documents to the insurer in the proper format and don’t unwittingly sabotage your claim.

• All communication with the insurer goes through your lawyer. You don’t have to waste your time and energy dealing with the insurer, and you don’t have to worry that you’ll make some error that lets the insurer turn down your claim.

• If your claim is denied, your attorney will know the appropriate next step to take, whether resubmitting the application with additional documentation, pursuing an internal appeal, or filing a lawsuit.

• The insurance company will evaluate your claim every month, causing unreasonable delays or leading to early termination of your benefits. You need expert help in responding to requests and dealing with insurer communications.

• They have lawyers evaluating your situation and developing legal bases to deny your claim or cut off your benefits. Level the playing field by having your own attorney and choosing one with as much experience or more than the insurance company lawyers.

Gianelli & Morris Takes on the Insurance Giants and Wins

Our California insurance law firm has gone up against the largest insurers in the state time and again and has consistently prevailed through individual claims and class actions across the spectrum of insurance law. Call our office if you are having difficulty getting approved for LTD benefits from your insurance provider. Some of the biggest providers of LTD policies are:

• Lincoln Financial
• Reliance Standard
• Liberty Mutual
• Mutual of Omaha
• Northwest Mutual
• Ameritas
• Principal Financial Group
• The Standard
• Mass Mutual
• Guardian
• Ohio National Financial Services
• Prudential
• Met Life
• CIGNA
• The Hartford
• UNUM

You Are a Medical Expert. Let Our Legal Experts Help You With Your LTD Claim.

LTD insurance policies can be lengthy, dense and highly technical. Despite your advanced education and training in the medical field, you might still find the esoteric language in your policy to be virtually impenetrable. At Gianelli & Morris, we live and breathe insurance policies and can quickly interpret your policy and let you know where you stand if your benefits have been denied. Whether your policy is Own Occupation or Any Occupation, ERISA or non-ERISA, we have the knowledge, skills and resources necessary to make sure you get the benefits of the policy you paid for. Call Gianelli & Morris today for a free consultation at 213-489-1600.

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