Q: What is the difference between an Own Occupation disability insurance policy and other types of disability insurance?

A: “Own Occupation” insurance insures you against becoming unable to perform “the substantial and material duties of your own occupation in the usual and customary way and with reasonable continuity.”. This coverage pays a monthly Total Disability benefit if you can no longer perform the important duties of your profession as, for example, a neuro surgeon, or ER doctor, or periodontist, or chiropractor etc. Benefits with this type of coverage are payable regardless of whether the claimant can perform his/her duties on a part time basis or can perform other types of work.

Q. Who is responsible for regulating the Insurance Industry?

A. Each state has a Department of Insurance, which is responsible for regulating insurance companies doing business within its’ borders. The duties of each state insurance department include:

  • Overseeing insurance companies and agents.
  • Promulgating and enforcing regulations to which the insurance company must adhere.
  • Handling consumer complaints about alleged unfair sales or claims tactics.

Q. What happens when there are ambiguities in the wording of an insurance policy?

A. There are a number of important rules that apply to theinterpretation of insurance policy language. For example: :

  • Any ambiguity in an insurance policy has to be interpreted in favour of the policyholder and against the company.
  • Words used in a policy must be interpreted according to the plain meaning that a layperson would attach to them, not as an attorney or insurance expert might read them.
  • Coverage provisions will be interpreted broadly. Exclusions and limitations will be construed narrowly.
  • Insurance contracts are interpreted so as to accomplish the ‘objectively reasonable expectations of the insured.’

Q. What is a “Statute of Limitations?”

A. A statute of limitations is the maximum amount of time that one has to file a formal lawsuit or claim. Statutes of limitation applicable to a particular claim depend on the policy, the theory of a particular case, and the laws of the state in which the filing of a claim is proper.

Q. What is ERISA preemption and how does it affect your rights?

A. ERISA is an acronym for the Employee Retirement Security Act of 1974. ERISA severely limits policyholder rights to insurance obtained through most employers.
Doctors receiving insurance benefits through certain health care organizations, such as Kaiser Permanente, are governed by ERISA
This law takes away the claimant’s right to a jury trial and bars recovery of consequential damages, general damages, or punitive damages. For that reason, policyholders have no leverage to force the insurance company to do what it is required to do under the policy and under state laws.
The whole subject of “ERISA Preemption” is very controversial. It is extremely unfair to medical professionals and others who receive disability or any other insurance through their work.

Q. What standards must an insurance company follow, in non ERISA cases, in evaluating a disability claims?

A. Insurance companies are required to conduct a fair, objective and thorough investigation before denying a claim. The insurance company must also::
• Refrain from putting its financial interests above those of its claimants.
• Avoid misrepresenting the terms of its coverage; and
• Pay benefits promptly.
In most states companies are required to act reasonably in its claims decisions. Failing to do so violates the duty of good faith and fair dealing that is implied in every insurance contract. In such a case, the insurance company can often be held responsible for any damages they have caused in addition to the contract benefits.

Q. What are the most common disabilities suffered by medical professionals?

A. Arthritis, fibromyalgia, chronic fatigue syndrome, neck, back hand, arm, wrist and finger injuries, cardiac conditions, mental and nervous disorders, substance addictions, diabetes and cancer.

Q. Beyond the restrictions and limitations from the medical conditions themselves, what are the most common additional problems associated with disabling conditions?

A. The side effects of prescription drugs, depression and the effect of the disability on issues related to informed consent and E and O insurance.

Q. What are some of the most common reasons given by disability insurers for denying or underpaying a disability claim?

A. N.B. This is a very incomplete list:

  • We disagree with the opinion of your treating physicians.
  • Our vocational assessment concluded that can still perform your important duties.
  • You are still performing some work and so you are Residually Disabled not Totally disabled.
  • You told our claims adjuster X and now your lawyer is telling us Y.
  • Our surveillance tapes show you carrying groceries/exersizing/playing golf/driving. If you can do any of these things you can treat/operate on patients.
  • You told our investigator you were tired of filling out all the insurance forms required these days and that you would rather spend more time travelling and enjoying life.
  • You recently had a baby and you want to stay home. (Used with both men and women).
  • You are having issues with your business partners and you want to move on with your life.
  • (Ignoring co-morbidity) you are clinically depressed and therefore the two year limitations restriction in your policy is applicable.
  • You left out material information on your insurance application and therefore we have the right to rescind (eliminate) your coverage.
  • You refused to meet with the IME doctor we selected for your insurance medical examination on the pretext that he was located eighty miles away. Therefore you are in violation of the cooperation clause in the policy.
  • According to our in-house psychologist, who reviewed your chart, you appear to be malingering/exaggerating your condition.

Q. What are some of the bad/negative things that can happen if a claimant handles his/her own claim.

A. You learn the hard way that your insurance company knows more about the ins and outs of the policy it wrote, the claims process, the insurance law of your jurisdiction, the relevance of discount rates and present value assessments, the fine print in its’ definitions section, or the advantages of filing a pre-emptive Declaratory Relief suit against you in a County with the most pro insurance judges in the state.
You learn this after it is too late.

Q. Do lawyers that advertise on television as disability law experts know what they are talking about?

A. No.