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Guidance on making a disability claim

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  • Guidance on making a disability claim

    How have others gone about submitting a disability claim?  Have you used an attorney?  Made the claim yourself?  My agent suggests doing it myself, but this is for big money.  I don't want to mess it up with a technicality or not presenting the issue correctly.

    FYI, I have own occupation.  I am still able to work within my specialty, just not my subspecialty.

  • #2
    Given the fact that you can still practice in your specialty, I think you will find that the company will do whatever they can to limit their exposure. I would encourage you to speak to an attorney who does this type of law frequently.  You will lose a percentage off the top but it could end up saving you tens or hundreds of thousands of dollars over the long run if you end up having to fight it, even if you eventually wn.


    • #3
      You should visit with the company first, and  if you don't like the answer they give you, then you can engage an attorney.  If you do have a true own specialty definition of disability in the contract but are still able to work in the occupation but not the sub-medical specialty, be ready to show what you were doing before the disability, what that specialty work created from an income standpoint, and why you are now not able to do that work.  Typically the carriers will simply look at the CPT code billing that you were doing prior to the disability, figure out how much income you were making from the things you can no longer do and then calculate what your income loss really looks like.  On true own occupation contracts, if the sub-medical specialty income was the majority of your income then fully benefits are typically paid out, if was not the majority of income then you are probably going to be on a partial claim.  An example would be an Orthopedic Surgeon who injures his/her dominate hand and can no longer practice surgery, but he/she can still be a practicing Orthopedic Physician, with the right contract then full benefits are paid regardless of future income.  Some definitions in the individual disability contract market and all association based plans currently in the market would have benefit reductions due to the future income.
      Scott Nelson-Archer, CLU, ChFC
      281-770-8080 Direct / [email protected]


      • #4
        These companies will do what they can to not pay you. The more nuances there are to your claim, the more they will try to avoid paying you. If you can not do hand surgery but could do generally ortho, they will challenge you on how you can do one but not the other.


        Another thing to keep in mind is that a disability lawyer may charge a smaller percentage if you engage them early and they help you even if they eventually deny you and they then have to fight it. They may charge a larger percentage if you engage them after a denial.


        Lastly, it might be true that these companies will think twice about denying a claim if you already have an attorney involved. You will give up some of your benefit by hiring someone but it may end up saving you a lot of time and frustration. Probably no harm in speaking to someone before you make a claim.


        • #5
          Keep in mind that many law firms will handle your claim on an administrative basis, file the forms for you and act as the liason between you and the insurance company.

          This will not cost you a percentage of your benefits and put you in a good position on the event things do not go as you think they should.
          Lawrence B. Keller, CFP, CLU, ChFC, RHU, LUTCF


          • #6
            In my research I'm finding a very wide range of fees and fee structures with the lowest being $7k (step by step advice including how to fill out forms but not actually dealing directly with theinsurance company on my behalf) to 1/3 contingency (handling every aspect of process including monthly follow up).  So there's a tax free delta of 100k+ in two years.  Of course there's nothing if my claim is denied.

            The reason I am considering an attorney is that regardless of how legitimate my claim, I am positive they will look for reasons to not pay.  And as Doug noted, there will be nuances. Though I read my policy as clearly saying own occupation for my sub specialty with total benefit (not residual), they may not.

            Finally, disability is highly unpleasant, and I don't want to deal with providing proof every month, but at 33% of the payout (and I followed WCI advice on amount and quality of policies so there is a considerable financial stake) I may just do it.

            Please PM if you have a specific recommendation for an advisor or an attorney.


            • #7
              Depending on the company I would suggest starting the process on your own as a client (assuming your disability does not prevent you from doing so) with the help of your advisor/agent.  In 15 years in the industry I have had 10 disability claims (6 on clients I have acquired and 4 on "orphans").  Each time not only was the claim paid but the company actually backdated the claim to speed up the payments.  And no lawyers were involved.

              You have been paying for this policy for just this event.  Assuming you believe the validity of the claim (and I would imagine that you do) I would not go the path of legal counsel right off the bat.


              • #8
                Anecdote:  I have a friend who filed for disability.  It was a pretty straightforward claim, and while it took a while for it to be reviewed ( it sat on the physician reviewers desk for a while ) it was approved without any reservations, and the checks have been rolling in, along with a COA adjustment.

                I would try just applying.  Don't start talking about which specialty and subspecialty you can do or not do. Just file, say you can't do "name of subspecialty", and see what happens.   If they want to quibble about what your specialty is or isn't, and what you can or cannot do, don't reply and talk to a lawyer then.  Don't do contingency. Find someone who will work by the hour.

                They aren't going to tell a surgeon who can't operate to do office consults full time.



                • #9
                  Depending on the language of your policy.....they might tell you that you could be the clinic consultant.  It just depends on what your policy definition states and how they are defining your specialty.  Depending on the company they can define it as your medical sub-specialty, being an MD / DO, Department of Labor definition of your occupation (not all medical specialties are recognized by the DOL), or based on your Education, Training, OR Experience.

                  It is just very important to know what language is present and what language is not present.  As an example the AMA states it has an Own Occupation specialty definition all over its sales material but when you read the definition in the policy it states once you have satisfied the elimination period (which is Totally and Continually disabled for the day quantity selected) if you can not perform the material and substantial duties of your medical specialty then you are benefit eligible unless you are engaged in another occupation for wage or profit then you might be eligible for residual benefits.

                  I have attached a list of definitions that typically get suggested are Own Specialty definitions when in fact really only the #1 definition is.....language matters in these contracts!  Hopefully at the time of purchase you selected the best definition possible since now that will provide the most flexibility and personal choices in future work.
                  Scott Nelson-Archer, CLU, ChFC
                  281-770-8080 Direct / [email protected]


                  • #10
                    Hi:  My firm represents doctors and other professionals in the preparation and submission of long term disability claims across the country.  We currently have nearly 300 clients in our Claims Unit, most who are being paid their benefits.  We typically handle these claims on a fee for service basis because it is usually more fair, but we also represent clients on a contingency fee basis, or a mix, depending on the circumstances.  I would be happy to take a look at your policy(s) and discuss with you both the long term disability claims process and the possibility of engaging my firm to assist you.

                    Thanks, Evan.



                    [email protected]



                    • #11
                      I'm in a similar situation and I've been working with Evan Schwartz (above in this thread) and found him to be very experienced and offering excellent advise. We reviewed my policies and medical records and I've asked him to help guide me through the process so I don't run into a problem.


                      • #12
                        WCICON24 EarlyBird
                        Just wanted to say thank you all for starting this thread and sharing your info. Found it uber helpful in consideration w/ filing a claim. Grateful for the recs and referrals above!