How an Attorney Can Help a Surgeon with a Denied Long-Term Disability Claim

The lawyers at Robinson & Warncke understand that your ability to perform delicate and demanding procedures as a surgeon is more than just a career; it’s a calling. The physical and mental demands of your profession require precision, stamina, and intense focus. Unfortunately, injuries, illnesses, or other debilitating conditions can impede your ability to practice, forcing you to rely on long-term disability (LTD) insurance to support you during such difficult times.

In this article, we will explore how a skilled attorney can assist surgeons in navigating the complex landscape of denied long-term disability claims and help secure the benefits they are entitled to. In addition to helping physicians and surgeons whose claims have been denied, including litigating those claims in court, we have also helped dozens of surgeons with their initial claim applications to ensure that the claims are accepted from the start so that our clients are able to get what they  expected when they purchased their disability policies.  In the face of a chronic illness, this often involves planning in advance for the inevitable day when despite your best efforts, you reach that point where you no longer feel you can effectively and safely continue performing procedures.

Understanding Long-Term Disability Insurance for Surgeons

Long-term disability insurance is designed to replace a portion of your income if you are unable to work due to a disabling condition. For surgeons LTD insurance is particularly important as it provides financial protection in the event that a disability prevents them from performing their surgical duties. Most surgeons have LTD policies, either through their employer or through individual policies they’ve purchased. Many of our clients have both forms of insurance.

The law and claim procedures differ for policies obtained privately/individually and for those obtained through an employer. Knowing these differences is crucial, making this one of the most highly specialized areas of the law.  Attorneys who do not do this work regularly are likely to miss important details, potentially affecting the ultimate outcome of the claim.

Regardless of the source of coverage, long-term disability policies typically cover a percentage of your pre-disability income and may define disability in one of three ways:

1. “Own Specialty” Coverage: this is the highest and best form of disability coverage, and the only kind of insurance a surgeon should ever consider. These policies generally pay benefits if you are unable to perform the important duties of your board-certified specialty. Benefits are payable even if you could perform a less demanding version of medicine (for example, seeing patients in an office setting, doing urgent care, or teaching). This distinguishes “own specialty” coverage from “own occupation” coverage.  Within the “own specialty” class, some policies include additional qualifiers, such as classifying surgery as a material duty of the physician’s practice only where the physician derives more than 50% of his or her income from performing surgeries.
2. “Own Occupation” Disability: This type of coverage pays benefits if you are unable to perform the specific duties of your “occupation,” which is usually defined with respect to the entire field of medicine.  These policies might not pay benefits under circumstances where “own specialty” policies would.  For instance, if you have a medical condition that interferes with your duties  as a surgeon, but you are able to see patients in a clinical setting or perhaps work in Urgent Care seeing non-surgical patients, you might not meet the policy definition of disability, so benefits would be denied.
3. “Any Occupation” Disability: This coverage is far more restrictive even than “own occupation” coverage. These policies pay benefits only if you are unable to work in any occupation for which you are reasonably qualified by education, experience, or training. Most competent insurance agents would advise against a surgeon ever taking out this kind of coverage. However, some large employer-sponsored group policies contain this definition of disability once twenty-four months of benefits have been paid. Many of the disputes we have handled have involved termination of benefits at this milestone/definition change.

Given the importance of your work and the potential for high income loss, securing benefits from an LTD policy is essential in the event that you become disabled. However, regardless of the type of insurance, LTD claims are often denied, leaving surgeons in a precarious financial situation. There are many things you can do to avoid this outcome, but specialized experience and knowledge is critical to ensure you get what you paid for out of your policy.

Common Reasons for Denial of Long-Term Disability Claims

LTD claims can be denied for a variety of reasons, many of which are specific to the unique nature of a surgeon’s work. Some of the most common reasons include:

1. Insufficient Medical Evidence: Insurance companies may argue that the medical evidence provided does not substantiate the severity of your condition or your inability to perform surgical duties. Insurers have access to physical consultants who review your medical evidence to determine whether “restrictions and limitations” are supported.  These physical consultants are often very demanding or even outright unreasonable in how they interpret the evidence.
2. Definition of Disability Disputes: There can be disagreements over whether your condition qualifies as a disability under the terms of your policy, particularly if the policy requires an “any occupation” standard.  Sometimes insurance companies take surprising positions as their policy interpretations.  Many claims also turn on whether, based on the particular policy provisions and your billing codes, surgery is considered a material and substantial duty of your occupation.
3. Pre-existing Conditions: Your claim may be denied if the insurance company believes your disability is related to a pre-existing condition that was not disclosed or covered by the policy.
4. Surveillance and Investigation: Insurers may conduct surveillance or investigations to gather evidence that contradicts your claim of disability, such as footage of you engaging in activities they believe you should be unable to perform.
5. Policy Exclusions and Limitations: Policies often contain exclusions or limitations for certain conditions, such as mental health issues or substance abuse, which can lead to denial.
6. Administrative Errors: Simple errors in filing, documentation, or communication with the insurance company can also lead to a denial.

How an Attorney Can Assist with a Denied LTD Claim – or, Better Yet, Make Sure the Claim is Accepted at Inception

If your long-term disability claim has been denied, it’s crucial to understand that you are not without recourse. An experienced attorney can provide the guidance and representation needed to challenge the denial and pursue the benefits you deserve.

Many of our surgeon clients do not wait for the denial to hire us.  They understand that the process is unfamiliar and full of pitfalls, so they hire us to assist with the original benefit application. It is easier and cheaper to ensure the “train stays on the tracks” from inception than it is to lift it back on the track after a derailment.

Here’s how an attorney can help:

1. Thorough Review of Your Policy and Denial Letter

The first step an attorney will take is to conduct a thorough review of your LTD policy (and the denial letter in the event of a denial). Understanding the specific language of your policy is crucial, as it outlines the definitions of disability, the terms of coverage, and any exclusions or limitations. The denial letter will provide the insurance company’s reasoning for the denial, which your attorney will analyze to identify any weaknesses or areas for challenge.

2. Gathering Comprehensive Medical Evidence

One of the most critical aspects of presenting an LTD application or appealing a denial is providing sufficient medical evidence to support your disability. An attorney will work closely with your healthcare providers to ensure that your medical records, test results, and physician statements clearly demonstrate the nature and severity of your condition.

For surgeons, this might involve obtaining detailed documentation that highlights how your condition impairs your ability to perform the specific duties of surgery, such as fine motor control, physical endurance, or cognitive function.

We also often recommend testing to better verify and measure your work restrictions. Oftentimes this testing is not necessary from a treatment perspective; it is done solely to prove your disability. We wouldn’t recommend this kind of thing unless we knew it worked. And it does.

Your attorney may also seek opinions from medical experts who can provide additional insights into your condition.

3. Strengthening the Appeal with Expert Testimony

In some cases, it may be necessary to involve retained expert witnesses to strengthen your appeal. These experts can include medical professionals, vocational experts, or even fellow surgeons who can attest to the demands of your profession and how your condition prevents you from fulfilling those demands. An attorney will identify and retain these experts, ensuring their testimony is persuasive and relevant to your case.

4. Challenging the Insurance Company’s Tactics

When it comes to claim denials, insurance companies often use aggressive tactics to deny claims, such as surveillance, independent medical examinations (IMEs), or vocational assessments. Every claim review involves a review of the medical evidence by an insurance medical consultant. We have seen hundreds of these consultant reports and some of them are less than fair.  Some are outright bizarre.

An attorney will challenge any evidence obtained through these methods that is used to deny your claim. For example, if the insurance company relies on an IME report that disputes your disability, your attorney can challenge the credibility of the IME doctor, question the methods used during the examination, or provide counter-evidence from your treating physician. Similarly, if surveillance footage is used to argue that you are not disabled, your attorney will contextualize the footage to demonstrate that isolated activities do not reflect your overall ability to perform as a surgeon.

At minimum we will obtain direct rebuttal testimony and possibly objective testing to challenge any questionable assertions from insurance medical consultants.

5. Handling Administrative Appeals

All employer-sponsored LTD policies require that you go through an administrative appeals process before you can file a lawsuit. This is required under the federal law that governs employee benefits, called ERISA.

ERISA is a real minefield for the uninitiated. If you fail to appeal on a timely basis, your claim is dead forever. Moreover, if you fail to include important evidence in your appeal, an attorney often cannot fix the problem later. The appeal is your final opportunity to submit evidence – with some very limited exceptions. So the appeal is the most critical phase of the process and where a specialist attorney can have the most positive impact.

An attorney will prepare and submit a comprehensive appeal on your behalf, addressing the specific reasons for denial and presenting all relevant evidence to support your claim.

The appeals process is governed by strict deadlines and procedural rules, making it essential to have legal representation to ensure that your appeal is timely and complete. A well-prepared appeal can often lead to a reversal of the denial without the need for further litigation.

6. Pursuing Litigation if Necessary

If your administrative appeal is unsuccessful, your attorney can file a lawsuit against the insurance company. Litigation involves taking your case to federal court, where a judge will review the denial and the evidence presented.

Litigation is a complex and resource-intensive process, but it may be necessary to secure the benefits you are entitled to. An experienced attorney will represent you throughout the litigation process, from filing the initial complaint to presenting your case in court.

7. Negotiating Settlements

In some cases, the insurance company may offer a settlement to avoid the costs and risks of litigation. Your attorney can negotiate on your behalf to ensure that any settlement offer is fair and reflects the true value of your claim. This can be particularly beneficial if you prefer a lump sum payment over the uncertainty of ongoing litigation.

The Importance of Legal Representation

A denied long-term disability claim can be a devastating blow, especially for a surgeon whose career and livelihood are on the line. However, with the help of a skilled attorney, you can avoid denial entirely by having an Atlanta, GA LTD attorney assist with the initial application.

And if your claim has been denied, an attorney can challenge the denial and fight for the benefits you deserve. An attorney’s expertise in navigating the complexities of LTD claims, combined with the experience in gathering compelling evidence and challenging the insurance company’s tactics, provides you with the best chance of success. If you are facing a denied long-term disability claim, don’t go it alone—seek legal representation to protect your rights and secure your financial future. Call Jeff and Doug today, they will fight for you.