How to avoid disability claim landmines

Questions to consider when submitting and following through a disability claim

Chiropractors who submit disability claims but are not familiar with the complicated process,  and do not receive proper advice, have little control over the outcome of their claims. Potential monthly benefits could be in the millions of dollars, yet often a cavalier approach is taken to this important life-saving benefit.

You wouldn’t want me to do a “side posture” or other adjustment on your spine, as I have no experience or training to perform the job properly. In the same vein, in order for you — not the insurance company — to exercise control over a claim, you must know the answers to a number of questions.

Not knowing can make the difference between success and failure, and affect the amount of money that will flow into your bank account. Some of these questions relate to how you handle matters before a disability claim, and some will relate to what you do during or afterward:

Corporations vs. individuals — If you are a corporation, should you have the corporation deduct the disability premiums as a business expense? Will that influence the amount of benefits you receive that are tax-free? If premiums are paid by the corporation, can it prevent you from claiming “bad faith” if you are forced to sue the insurance company? Can you reverse the premium paying process where you do not take a business deduction and receive monthly benefits tax-free? Will the same apply to the “bad faith” issue?

State and federal benefits — If you are in a state that offers state disability benefits and you have paid to be covered, will these benefits be deducted from your personal disability benefits? How about Social Security disability benefits if eligible — will they be deducted? And what if you have an association group plan and a group plan where there is an employer/employee relationship (your office plan or an office you work for) — will there be any “offsets” (deduction of monthly benefits) by one plan of the other? Could you wind up with neither insurance company paying?

Sell or hire help? — If you own your practice, should you sell the practice before or after you go on total disability claim? If you have a partial disability claim and you hire another chiropractor, will the insurance company consider just your earnings based on your production, or will they consider the earnings of the office (less business expenses)?

Additional areas to consider:

Physicians and statements

You’ll need to ask your own doctor if he/she or their staff have ever taken a course related to the completion of disability claim forms — the Attending Physician Statement. It is crucial that their office knows the difference in contractual wording as it relates to partial or total disability, between your personal disability policy, group disability, association disability, state disability, and Social Security disability or worker’s compensation.

Also, will only one physician statement be required, or will one be required for each of your treating physicians, and will that have an influence over the control of your claim? You can also determine if there is anything you can do to cause the insurance company to accept only one attending physician’s statement.

Working with claims and policy

Individuals working with your claim can change, so when you get a new claim person assigned to your existing disability claim, you need to make sure they’ve reviewed your entire file from the beginning. If not, that can influence their thinking and approach to you receiving future benefits. You’ll also need to know the difference between “Your Occupation” definitions. A “pure” total disability definition differs from a “modified” definition and a definition that relates to your “education, training and experience.”

You could also be offered a buyout of your disability policy, where you would need to determine if you’re receiving a fair offer, and if there is room to negotiate.

Partial and total disability

A partial disability claim can, depending on circumstances, turn into a total disability claim, requiring that you learn best practices for such a transition. Also pay attention to the definition of total disability — is it defined based upon your profession/occupation at the time you purchased a disability policy, or at the time you claimed disability?

If you keep your disability policy past age 65, there is usually a requirement that you must be working full-time. Do you know what “full-time” means? Is it three days per week? Four days per week?

Claim forms and language

Most chiropractors are ill-prepared and get the answer wrong when asked, “How many people do you employ and how many people do you supervise?” You’ll also need to interpret policy contractual language such as preexisting conditions, fraudulent misstatements, prudent man clauses, incontestability, presumption of disability, etc.

Also, what is the risk of an insurance company saying you have “dual occupations”?

Exams and field investigators

What are your options when an insurance company requests that you be examined by a physician they pay for? Are you required to attend such an exam? What if they request you be “tested” by a physical therapist for three hours or more … are they permitted to do so? Are you allowed to receive a copy of these reports?

If a field investigator approaches you at your residence, are you required to read, sign and date a document they hand you in response to questions that were asked of you?

Don’t short-change yourself

You are prejudicing your right to collect on a legitimate disability claim unless you know the answers to the above questions, and the many more that arise while you are applying for disability benefits or attempting to keep an existing claim from being discontinued.

Control of a disability claim will provide a higher rate of success, and also reduce the anxiety that goes along with the pile of paperwork you never imagined when you purchased your policy. 

ART FRIES is a disability claim consultant providing advice on a national basis in the U.S. He is located in Nipomo, Calif., and can be reached at 800-567-1911, friesart@hotmail.com or afries.com.