Successfully Navigating the Disability Claims Process

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BY VANESSA ORR

When it comes to disability insurance, many physicians either choose not to have it or don’t have enough. This is mainly because they don’t believe they’ll ever need it—or because they believe that if they do have a disability claim, the carrier won’t pay.

“Often the only time that physicians hear about disability insurance is when the comments are negative; when people have a problem,” explained Wes Caldwell, disability and benefits specialist at Danna-Gracey, the largest independent medical malpractice insurance agency in Florida. “If someone gets paid, they rarely hear about it. The fact is, most disability carriers pay claims in a timely manner for legitimate claims—if they didn’t, they wouldn’t be in business.”
When there’s a problem, it’s often because of physicians’ lack of familiarity with these types of claims, and a lack of resources to help.

“Unlike a lot of other insurance types, there isn’t really anywhere to turn to get information,” said Caldwell, who counsels clients about the most common mistakes that physicians make when filling out the forms.

One of the biggest obstacles to claim approval, he says, is a lack of communication between the insured physician and his or her treating physician, who determines if the disability affects the claimant’s ability to practice.

“You have to make sure that you’re both on the same page; you need to tell your treating physician what you are going to communicate to the insurance carrier,” Caldwell explained. “Physicians write a lot of things in their notes, so it’s important to be aware of what they’ve written.”

While carriers do have the ability to bring in independent physicians to verify a disability, it is initially the treating physician who determines a claimant’s ability to work.

Filing a Claim
Generally, most carriers require physicians to notify them of a claim within 30 days of a disability, and most policies have a 90- or 180-day waiting period before benefits can be received.
“Physicians sometimes confuse the two, and wait 180 days to file a claim, which is a mistake,” said Caldwell. “If you have a condition that is hindering your ability to practice—not like the flu, but something that may last three to six months or longer—file the claim within 30 days; you have nothing to lose.”

Both the claimant and his or her treating physician will receive forms to fill out that include information on practice duties and a health history, and it’s important that the information on these forms match.
“The majority of delays are caused by conflicting information on those two communications,” said Caldwell. “That raises red flags with the claims examiner.”

Caldwell recommends that physicians also contact their insurers’ claims departments to find out who will be handling their cases.

“These people are not there to deny claims; they are just working with the information coming to them, not knowing your specific situation,” he explained. “Opening up this line of communication makes it easier to resolve an issue if there’s a dispute.”

Caldwell adds that it’s important to remember that a legitimate claim is an illness or injury that limits or eliminates a physician’s capacity to practice, as determined by their doctor. “The problem with some physicians, especially those with bigger insurance policies, is they consider using these policies as retirement plans, which is exactly what carriers are looking for,” he said. “These policies are not to be used as a way out just because you don’t want to practice anymore and your back hurts.”

What If Your Claim is Denied?
All claims contracts have an appeals process, and some have more than one.

“My advice to clients is to follow the process; if your insurer says to send a letter with further information, follow those guidelines,” said Caldwell. “The majority of claims that have been denied will be resolved through that process.”

If a claim is denied on the first level, Caldwell advises clients to go to the second level. If the claim is still denied, it may be worth bringing in an attorney.

“One of the biggest mistakes that physicians make is to hire an attorney right off the bat; it’s the last thing you want to do,” said Caldwell. “It puts another layer of communication between the insured and the claims examiner, and takes the insured completely out of the conversation.

“If all of the appeals are denied, then they may want to consider bringing an attorney in, but even then, the physician should try to settle the case on his or her own,” he added. “There’s no harm in asking the carrier if they will settle; if they’re successful, it could save them a 30-40 percent attorney fee.”

For more information, contact Wes Caldwell at wes@dannagracey.com or (888) 284-4198.