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 Will I Have to Wait Before I Get My Long Term Disability Benefits?

Long Term Disability policy premiums depend on your age, gender, health history and your occupation.How Long for a Long Term Disability Claim?

An important factor is the policy elimination period. This is the length of time you go without getting benefits. Sometimes people choosing a ninety-day period of time to go without benefits at the onset of their disability. When the time is up, the Long Term Disability carrier will start paying your benefits. The longer your elimination period, the cheaper your premium. I’ve seen elimination periods as long as a year and I would not encourage that.

I would suggest a ninety-day elimination period.

You also get to choose how long you will get paid benefits. Most companies will let you chose benefits that last between two, five years to age 65, 67 or for the rest of your life. Quite frankly, it’s very difficult to find a policy these days that will pay a medical professional for the rest of their life and more commonly these disability policies will pay through the age 62 or 65.

Regardless of the price tag, remember you are insuring you and your ability to work. As the breadwinner you have the obligation to yourself and your family to provide them with support even in a time of your disability. If you have any questions about the Long Term Disability process, contact us today so we can get you on the right track in your claim. 727-894-3188.

FAQ – How Long Will It Take to Get An Initial Decision on my Disability Claim? | Hudson Long Term Disability Lawyer

You have sent in your claim for disability benefits and are now waiting to hear whether your claim has been accepted for whether it will be denied. How long will it take to get the initial decision on your disability claim?

Once the claim is received, a plan has 45 days under the ERISA regulations to make a decision. If more time is needed, a plan can notify you in writing asking you for an extension of 30 days. However, the plan must ask for this extension before the end of the 45 day time and can only ask for that extension because of “matters beyond the administrator’s control.”

And, guess what? The plan can ask for a second 30 day extension.  The plan has to ask for that second extension during the first 30 day extension.

So, we start out with a 45 day base waiting period that can be extended for 60 days for a total of 105 days.

But that period can be extended if the disability carrier sends you a request for information. That stops the clock!

If you want to start the clock again, you need to promptly provide the information that has been requested and send it certified mail. If the disability carrier asks for more information after you’ve sent in your claim, that’s another signal you need to retain an experienced disability attorney like Nancy Cavey.

The short-term or long-term disability carrier is looking for something specific and if you don’t give it to them is likely your claim will be denied. You probably won’t have a clue as to what it is they’re looking for unless you understand the policy terms and your medical records.

If you don’t have the information lto et the disability carrier know in writing sent by certified mail, return the receipt requested. If you are trying to get the information, notify them of any problem you are having and let them know what you’re doing to get this information.

Better yet, retain and experienced disability attorney. This process is full of pitfalls. Don’t be lulled into thinking you can give the disability carrier what they want and they will happily send you a disability check. Disability carriers are in the business of collecting premium and not necessarily in the business of paying disability benefits.

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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