You take out doctor disability insurance so it is there in case you ever need it. Unfortunately, as you might have already experienced with patients’ cases, insurance does not always come through as you expect.
Insurers that issue physician specialty-specific disability policies routinely scrutinize—and too often reject—legitimate claims. When a denial stems from administrative errors, incomplete documentation, or other improper grounds, you are entitled to challenge the decision through a formal appeal.
The terms surrounding doctor disability insurance policies can vary depending on who is providing them and whether they are group or individual coverage. But in every case, it’s important to act swiftly and assuredly to make your appeal. Working with an experienced physician disability attorney can help you strengthen your case and increase your chances of receiving the support you deserve.
Here are some considerations to make when organizing your appeal. And for more information, please check out our free ebook that goes into further detail.
EBOOK: The Doctor’s Disability Insurance Appeals Handbook
Why exactly was your claim denied?
When an insurance company denies your claim, you will most likely receive a letter identifying the reasons for their denial and how you can appeal.
It is of course important to read this letter carefully, as it outlines the foundation of the appeal argument you may need to make. In some cases, there might simply be paperwork that needs to be corrected or added. Other cases may involve much more work.
Does ERISA apply to your doctor disability insurance?
While many doctors have single plans, some have group plans through a practice group or larger employer, such as a hospital or medical system.
In these cases, it is likely that these employer plans fall under the federal Employee Retirement Income Security Act (ERISA). However, government-based and certain religious employers are exempt from ERISA.
If you are uncertain whether ERISA applies to your case, you should confirm with an attorney as soon as possible. That’s because ERISA places very strict rules and deadlines on the appeals process. Some restrictions to consider include:
- A 180-day deadline to file an appeal
- Having to exhaust all other administrative appeal options before filing a lawsuit against the insurance company
- Potentially limiting the evidence a court may review to whatever has been submitted to a claim file, often with no new evidence admissible during the review
If your policy does fall under ERISA law, it is important to begin quickly and accurately organizing your case for appeal. That includes:
- Requesting a copy of your claim file if the insurance company has not already provided one
- Gathering and reviewing all pertinent evidence to your claim such as medical records, vocational evaluations, communications with the insurance company, personal accounts, photos, and third-party testimonies
- Filing your appeal according to ERISA standards, along with a detailed appeal letter
Remember that you might only have one chance to submit your evidence. And unfortunately, even after following the appeal process perfectly and supplying solid evidence, the insurance company might still deny your claim. In that case, with all other options exhausted, a lawsuit can be filed against the insurance company.
If, on the other hand, your policy does not fall under ERISA rules, then your appeal process will be governed primarily by state law. This may give you more options for how you can approach making your appeal. You might also be able to file a lawsuit against the insurance company sooner, if necessary, and seek bad faith damages in addition to standard damages and attorney’s fees.
Again, an attorney with experience in handling doctor disability insurance cases can discuss and help you exercise your rights.
How does your policy define disability?
The majority of doctor disability insurance policies fall under an “own occupation” definition of disability. This means that the insurance company should pay benefits if you are no longer able to perform the duties of your specific occupation. This is opposed to an “any occupation” definition, where benefits are only provided if you can no longer gain any type of gainful employment whatsoever.
The “own occupation” definition seems perfectly reasonable for doctors and physicians who have specialized skills. And being unable to perform those skills anymore can seem a cut and dry reason to have your insurance claim play out. But it’s not always that simple.
Insurance companies can sometimes use wording and loopholes to deny doctor disability claims. Instances include:
- Defining disability around being unable to perform “material functions.” In other words, you might not be able to perform crucial parts of your job, but as long as you can perform even basic consulting or evaluating work, your claim may be denied.
- Changing the parameters of your occupation over time. As doctors age, they might shift their duties to take on less specialized work. The insurance company might consider the changed set of duties to be your “own occupation” and judge your claim based on these roles instead of the original qualifications.
- Enforcing exclusions based on pre-existing conditions, active military duty, certain disorders, and other factors.
RELATED: “Own Occupation” Disability Insurance Policies: A Guide for Doctors
Understanding the full terms of your doctor disability insurance policy can help you more directly and effectively appeal a denial, saving time that might have been spent pursuing dead ends or misunderstandings. A disability insurance lawyer can help untangle the language that may trip up the appeal process and identify potential targets within the policy that can strengthen the success of your strategy.
Need Help with Your Doctor Disability Insurance Appeal? Contact Bryant Legal Group
An insurance appeal is not something you need to take on alone. Bryant Legal Group has spent years helping professionals in Chicago and throughout the region overturn denials and receive the compensation they’ve deserved.
We know the ins and outs of disability insurance. We will be happy to answer questions about your case, suggest your next steps, and represent you if we can be of further help.
Request a free consultation with one of our attorneys by calling (312) 757-7269 or by filling out our online contact form.
The content provided here is for informational purposes only and should not be construed as legal advice on any subject.
The post Doctor Disability Insurance: How to Appeal a Claim Denial appeared first on Bryant Legal Group.