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.

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