How to File a Disability Insurance Claim for Physicians
Almost everyone that has disability insurance bought their policy with the hopes of never having to use it. But the fact is that 25% of people who are currently twenty years old will be out of work for at least a year due to a disabling condition before retirement.
When those injuries, illnesses, and disabilities occur, not only will you need disability insurance, but you’ll need to know how to file a claim.
The cost of disability insurance varies from policy to policy, with the average plan paying benefits of about 60% of your gross salary. That 60% of your income can be the difference between being able to pay your mortgage and daily living expenses or depleting your savings.
Today we’re discussing how to file a disability insurance claim for physicians.
We’ll cover how to file, when to file, and what you can do to protect yourself so that you collect the disability income you deserve.
Understand Your Policy
Every disability insurance policy has its own sets of terms, requirements, and limitations. Before you even consider filing a claim, make sure that you know the key factors that will determine if and when you are eligible to collect disability insurance benefits.
While most policies include their fair share of “fine print” details, there are three main things you need to be aware of:
- What your disability policy does and does not cover
- How you’ll have to prove your disability
- What your elimination period is
What Does Your Policy Cover?
Do you have a short-term disability policy?
Are you eligible for long-term benefits?
Can you collect partial benefits if you can still do part-time work?
Knowing what your policy covers is key to understanding if you will be eligible to collect benefit payments.
At Physicians Thrive, we advise all physicians to obtain long-term disability insurance. The best providers offer policies that will pay monthly benefits for at least until the age of retirement.
Many physicians have a short-term disability insurance policy through their employers. This can be a great job perk, but the benefit amount will only sustain you for a limited period of time.
In some specific cases, you can also draw on Social Security Disability Insurance (SSDI) in addition to your employer policy. However, the Social Security Administration will take the policy you already have and subtract that amount from what they’ll give you. It’s nothing to bank on — especially when you’re accustomed to high earnings.
If your employer offers you a short-term policy, it’s still best to seek an individual long-term policy for added, extended protection.
Depending on your insurance provider, you may also be eligible to receive partial disability benefits. Your disability may prevent you from doing a portion of your current job, thus reducing your income. Partial benefits can help subsidize that loss of income.
How Do You Prove That You’re Disabled?
Every disability insurance policy includes a definition of disability. This is the standard that you need to meet in order to be eligible to collect benefits.
There are three common definitions that most insurers use:
To be eligible for benefits under this definition, you must be disabled so severely that you cannot work in any job.
Own-Occupation, Not Working
To collect benefits with this definition, you need to be unable to work in your current job and choose not to work in another job.
This is the preferred definition of disability that we recommend physicians look for in a policy.
Under this definition, you can collect benefits as long as your injury or illness prevents you from doing some, part, or all of your current job. In some cases, you can do other types of work and still collect benefits.
Before you begin the claim process, make sure that you meet the definition of disability. If you do not, your claim will be denied and you will not be able to collect your benefits, regardless of how ill or injured you may be.
What is Your Elimination Period?
When you take out a disability insurance policy, you’ll need to choose an elimination period. This is the time period between the date you become disabled, and the date you can start collecting disability benefits. Most providers offer a variety of elimination periods ranging from a minimum of 30 days all the way up to 720 days.
Your elimination period doesn’t dictate when you can file your claim. Regardless of your elimination period, it is always best to file your claim as soon as possible. The elimination period only determines when you can start receiving benefits.
When to File a Claim
It’s likely that your disability insurance policy stipulates a time frame in which you need to file a claim. This is typically 20–30 days from the date of your injury or diagnosis.
What to Do Before You File
Your insurance provider will require you to fill out a claim form — but that’s only one small part of the documentation you’ll need to submit.
Before you file, gather medical records from your doctor.
You will need copies of your:
- Medical history
- Lab reports
- Test results
- X-ray and/or MRI reports, if applicable
You will be required to submit physician notes from appointments leading up to the diagnosis of your medical condition or date of injury.
Also, you will need a statement letter from your doctor to back up your claim. This letter should describe the nature of your illness or injury as well as the type of treatment you’ll need. There should be additional information that specifically states that you are not able to work or that the scope of the work you currently do will need to be limited.
Without the proper documentation, you can expect your claim to be denied.
How to File a Claim
As soon as you become ill or injured, contact your insurance provider. A phone call or a visit to their online portal is the first step in filing a claim.
Your provider will instruct you to fill out a claims packet. You can expect this to include a variety of forms, such as a claimant statement, a statement from your employer, and a statement from your physician.
If you want to receive your benefits electronically, you will also need to fill out a direct deposit enrollment form with your banking information.
Once you have all of your forms together, make copies. You should never submit your originals.
What to Do if Your Claim Gets Denied
Insurance companies have a reputation of being in business to make money and not to pay out. This comes as a result of policy holders experiencing what they would call “looking for any and all reasons to deny a disability claim.”
This belief is further exacerbated by disability insurance claims being routinely denied for all sorts of reasons. Most of the time it is because of poor definitions in the policy, exclusions or improper documentation. Below are some of the most common reasons claims are denied.
Your provider may:
- Say that you do not meet the definition of disability
- Claim that you did not submit all of the proper paperwork in the required time frame
- Refuse your claim based on your doctor’s notes
- Try to say that your disability is from a pre-existing condition that your policy excludes
This is why it is so important to understand the ins and outs of a policy before you agree to one.
If you think your provider has denied your claim unfairly, inform your lawyer. File an appeal as soon as possible. If your appeal is denied, your attorney may even suggest that you file a lawsuit.
How Physicians Can Protect Themselves (And Have Their Claims Approved)
As is to be expected, a lot of insurance companies look for loopholes and ways to deny disability claims.
While there are some good ones out there, many will try to deny your claim upon your initial filing. Don’t take their word for it or accept their first rejection as the final word. If you think you have a valid claim, consult a lawyer for a better understanding of your legal options.
But filing an appeal (or a lawsuit) should be your last resort. It’s better to be proactive in your approach and arm yourself with as much knowledge as possible before submitting a claim.
Here are five ways to protect yourself before you file so that your claim gets approved:
1. Consult With an Attorney First
Don’t wait until your claim gets denied to seek legal advice. Consult with an attorney before you file so you can protect yourself from the very start of the process.
2. Be Wary of Independent Medical Exams
Once you file a claim, your provider may ask you to undergo an independent medical exam by a physician (or some other “expert”) of their choosing. You do not need to agree to this or do this unless it specifically states so in your policy.
Even if an independent medical exam is part of the terms of your policy, you still have rights. You can have your lawyer or your own medical representative attend that examination with you. You can also request a copy of the independent examiner’s CV in advance so that you know who you will be meeting with.
It is also your right to limit the scope of that examination. You do not need to be subjected to painful, prolonged, or intrusive testing. You can refuse to have your exam recorded or videotaped. You can also demand that a copy of all notes or examination results be presented to you.
3. Visit Your Physician Several Times Before Filing
If possible, meet with your physician on multiple occasions before filing a disability claim. Your physician will take exam notes during every interaction. Documentation regarding complaints, injuries, and pain will be helpful in supporting your claim.
4. Be Way If You’re Asked to Quantify Your Time
If your insurance provider asks you to quantify your time at work, you can be sure they are looking for a way to deny your claim.
Quantifying your time means breaking down how many hours per week you spend doing each individual segment of your job. Depending on how you quantify your time, your provider may say that you’re only partially disabled.
Why? Because the more you quantify your time, the easier it is for them to say your injury only prevents you from doing a small portion of your job.
For example, if you own your own practice or also work as a medical director, your provider may claim that your administrative duties are significant enough that you can still do a substantial portion of your job.
Before you quantify your time to an insurance provider, consult a lawyer. By doing so, you’ll have a complete and total understanding of some key phrases in your policy, such as “principal duties” and “occupation.”
5. Be Aware of Surveillance
It is common for insurance providers to conduct surveillance on policyholders that file a disability claim. Assume that you are being watched at all times and avoid doing any activity that might make it seem as if you are exaggerating your disability.
Protect Yourself in Advance by Getting a Policy With a Top-Quality Provider
When you file a disability insurance claim, you expect to receive benefits. But that’s not always the case.
The best way to protect yourself and receive the benefits you deserve is to choose a top-quality provider. There are some providers out there who will do everything in their power to deny your claim. The “Big 6”, on the other hand, provide more flexibility and make it easier for physicians to collect the benefits they need.
The “Big 6” providers are those that provide the true own-occupation definition of disability. And that is the key to selecting a policy that will actually pay benefits when you need them.
For more information about the “Big 6”, check out our individual provider reviews for:
It should come as no surprise that the goal of most insurance companies is to only pay out as much as required and that usually means up to 50% of their total premiums with the other 50% being used for overhead. With that in mind, you can protect yourself by doing the following:
- Understanding your policy
- Knowing when to file a claim
- Having all of your documentation and records ready before you file
- Consulting with an attorney
- Knowing your legal rights as set forth by your policy
- Being able to identify the common ways that insurers try to deny claims
Paying monthly premiums is only valuable if your insurance coverage pays out when you need it. Do your research before you select an insurance carrier and policy. That will give you the best chance of securing your rights and collecting the benefits you deserve.