If You Are a Physician and Don’t Understand How Long Term Disability Carriers Use CPT Codes in Analyzing a Claim for Disability, You’ll Hate Yourself Later

Many physicians will have what is called an “own occupation” disability insurance policy that will pay benefits if you are no longer able to carry out the duties of your own occupation.Physician Long Term Disability Lawyer

Unfortunately, many physicians don’t understand the games that long term disability carriers will play in determining what a physicians “own occupation” might be at the time that they become disabled.

For example, a UNUM disability policy provides for “total disability” benefits when the insured, due to injury or sickness is “unable to perform the important duties of his occupation and is under the regular care of a personal physician”. Dr. Natarajan, a board certified Cardiologist, had such a policy through Paul Revere Life Insurance Company and UNUM. Dr. Natarajan opened the first cardiac catheterization in Venice, Florida and, following the adoption of innovational cardiology, Dr. Natarajan became certified in interventional cardiology in the year 2000.

Unfortunately, he developed severe arthritic degeneration in his hands and lost his ability to perform the surgeries.

As a result, and over time, he had to reduce the number of cardiological interventional procedures he conducted.

He filed a claim for total disability benefits and, as part of the claim UNUM completed the medical billing review/ CPT Code Analysis.

Based on UNUM’s analysis, they concluded that surgical or invasive/interventional procedures only accounted for 12% of the total number of procedures performed by Dr. Natarajan and accounted for only 25% of all the billings and charges prior to the onset of his disability.

In line with the CPT Code Analysis, UNUM determined that Dr. Nataregan was not engaged in a specialty of invasive/interventional cardiologist on account of his disability.

They concluded, that he was a general cardiologist, since he maintained a limited office practice as a cardiologist, he was not entitled to total disability benefits.

UNUM suggested that he seek the payment of residual disability benefits and Dr. Natarajan disagreed then sued Paul Revere UNUM Provident aka the UNUM group.

The court held that the policy defined “Your Occupation” as the occupation in which “the [insured] is [readily engaged] at the time [the insured] becomes disabled” and that Dr. Natarajan had to demonstrate there was “evidence of means by which a reasonable jury might find he was employed as a interventionist/invasive cardiologist (as opposed to a general cardiologist) at the time he became disabled”.

The Court pointed out that Dr. Natarajan had “considerable evidence” including documentation that he was a board certified interventional cardiologist and the affidavit from the administrator of the facility where Dr. Natarajan was employed, which confirmed that he was specifically hired because he was an interventional cardiologist.

The Court denied UNUM’s motion for summary judgment, agreeing with Dr. Natarajan that the CPT analysis was, alone, insufficient to establish that Dr. Natarajan was a general cardiologist.

UNUM offered up it’s own claims manual in support of it’s allegation that they were entitled to apply “more narrow definition of own occupation”.

The Court rejected this interpretation in denying UNUM’s motion for summary judgment.

If you are a physician who has a “own occupation” policy, you should consult an experienced long term disability attorney to assist you in helping you understand your policy terms, how they carrier might limit your coverage, and how they may use the CPT Codes in denying your claim for benefits. Give us a call today at 727-894-3188 to discuss your policy.

How Long Term Disability Physician’s Companies Use The Dual Occupation Defense to Deny Physician’s Claims| Clearwater Long Term Disability Insurance Lawyer

Are you a physician who has multiple specialties or businesses? If so, you must properly protect yourself in the event that you become disabled, because one of the common defenses to a long-term disability claim is the “dual occupation” defense. What is this defense?

The long-term disability insurance company will argue that you have two or more occupations at the time you claim to be disabled. Because you’re able to work full time in one of those occupations, a long-term disability carrier will argue that you are not entitled to ANY benefits.

Let me give you some examples.

In Giampa v. Trustmark Insurance Co., 73 F.Supp.2d 22 (D. Mass. 1999), Dr. Giampa, a chiropractor, spent 85% to 95% of his pre-injury time treating patients by conducting examinations and performing manipulations or chiropractic adjustments. He injured his back, which limited his ability to perform manipulations. He had spent incidental time managing his two other chiropractic facilities before his injury.

After his injury, Dr. Giampa devoted all of his time to administrative duties managing the other chiropractic facilities, which resulted in a dramatic increase in his income. He claimed long-term disability benefits, which were denied.

His disability insurance policy had both a total disability clause and a partial disability clause.

The Federal Court decided that the total disability clauses should not be read so literally that an insured persons ability to perform some business duty, no matter how small, would prevent the finding of total disability.

Another twist on the dual occupation issue involved a dentist who had retired and begun working in the real-estate field.  He became disabled and filed a claim asking for the payment of long-term disability benefits based on his inability to perform dentistry. The court found that regardless of whether he intended, even after the sale of his dental practice to resume dentistry, dentistry wasn’t his regular occupation at the time he became disabled. The un-controverted medical evidence show that he was unable to perform most of the substantial material duties of his regular occupation as a real estate developer. The clause in the disability policy defined total disability as the inability to perform some substantial and material duties of his regular occupation. The long term disability policy  did not unambiguously require that he be unable to perform all of the substantial maternil duties of his occupation.

Another example involves the policy of a general surgeon who had on the side, developed a second business doing cosmetic surgeries including vein striping. Needless to say, that was far less stressful and more remunerative than doing general surgery. Unfortunately, he became disabled and unable to perform general surgery. Was he entitled to long-term disability benefits?

The answer could be found in the terms of the disability policy. He had a policy that looked at the occupation he was engaged in at the time of his disability and also had a residual disability provision. The residual disability provision paid benefits even if he was working at another occupation.

The residual disability provision said that “residual disability must follow right after a period of total disability that lasts as long as the qualification period, if any.” Huh?

This would seem to say that one could never get residual disability benefits, unless there was some initial period of total disability. Another question would be whether you had to be totally disabled from work as both a general surgeon and as a cosmetic surgeon to get benefits?

Another paragraph says that “This (residual disability benefit) will begin on either the commencement date or the day after the total disability ends up later.”  You could argue that if he are unable to do general surgery, but the same day could do vein stripping, the doctor  would be entitled to residual disability benefits.

You have significant choices to make and you can inadvertently shoot yourself in the foot and screw up your eligibility for disability coverage by making the wrong decision

It is crucial that you consult with a qualified long-term disability/ERISA attorney before you file your disability application to avoid making crucial mistakes that can result in the complete denial of your claim and cost you residual disability benefits.

You must determine what your policy says about the criteria for being disabled, what occupation your policy covers, whether there is a residual claim, what percentage of your revenue comes from both occupations, how your disability impacts your ability to perform both occupations, and how you’re going to prove that disability. That determination should be made BEFORE you even file your long-term disability claim.

Nancy Cavey, a long-term disability/ERISA lawyer, can be a great resource to you before you apply for long-term disability benefits. Nancy Cavey will be able to review your policy, advise you as to the best course of action to preserve your benefits and maximize your disability income, and assist you in gathering the necessary documentation to prove your entitlement to disability benefits.

Finding a lawyer with long-term disability/ERISA experience who has a proven background in dealing with physicians committee will make the difference between obtaining your long-term disability benefits or being denied. The lawyer who helped you set up your practice, helped you write your will and helped you purchase your house does not have the experience handling disability/ERISA claims.

Contact Attorney Nancy Cavey, who represents physician’s  through out the United States for more information on the dual occupation defense and to get your free no obligation copy of “Robbed of Your Peace of Mind.”

If you have any questions, please give us a call at 727.894.3188 or contact us online by clicking here.

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