| May
16 , 2005 ADA NEWS
Disability
claims for dentists
Disability claims for dentists are different.
Many individuals may be able to function at a job with
cervical, thoracic or lumbar problems, or work in a reduced
capacity. However, a dentist can be devastated from a
work standpoint if any of the above medical symptoms become
chronic and affect performance.
For some dentists, repetitive movements
on a daily basis in the performance of their duties puts
a strain on parts of their bodies. They reach a point
whereby they are holding back with respect to procedures
and/or are not effective in the treatment of patients.
Pushing one to do a proper procedure can put added stress
on injured areas and, over time, can possibly lead to
permanent damage. Sometimes, reducing hours of treatment
can help, and the dentist can continue working on a part
time basis. In other situations, however, it is necessary
for the dentist to stop performing clinical duties or
go on total disability.
Many individual disability policies that
have been purchased by dentists provide partial as well
as total disability benefits, often up to age 65 and sometimes
for life.
The wording is often occupation specific,
meaning that if you can’t perform the substantial
and material duties of a dentist but can work in another
profession or job, the insurance company will pay you
the full amount of the monthly benefit. Your ability to
work in your new job must be consistent with the symptoms
that disabled you from dentistry.
Although an insurance company may have
made certain promises in the way of a disability contract,
these broadly worded policies have left a trail of red
ink that has caused claim management practices by insurers
never envisioned by dentists when the policies were purchased.
In order to control the flow of money
from their banks, many insurance companies are using defensive
measures that make the claim process more difficult from
a claimant’s standpoint. These include a field investigation
(personal visit with you), independent medical evaluation
(medical exam by doctor paid and selected by insurance
company), functional capacity evaluations (tests conducted
by physical therapist paid and selected by insurance company),
video surveillance and use of forensic certified public
accountants.
A field investigation can be unannounced
or a specific appointment date can be arranged with claimant.
Sometimes the dentist is asked to read and sign a handwritten
statement prepared by the field investigator, summarizing
the aspects of the claim. This statement should never
be signed a the interview, but read carefully by the dentist
and returned to the investigator on another day with appropriate
corrections made.
With respect to independent medical evaluations,
I am seeing these performed with most claims even when
the claimant’s attending physician can verify symptoms.
The functional capacity evaluations are
also being used more frequently, but typically with those
claims related to muscular skeletal (cervical, thoracic,
low back) and hand and arms problems. I personally question
the ability of an insurance company requiring an FCE based
upon policy language that, in many cases, states the insurance
company has the right to examine you but often does not
say they have the right to test you. An FCE is a test.
Video surveillance is used to determine
if the dentist’s medical symptoms are in conflict
with the dentist’s personal lifestyle and actions.
Athletic and social activities are monitored closely early
on, and there can be multiple periods of video surveillance
over the life of a claim. A video surveillance team can
often even secure access to a guarded/gated community.
With respect to forensic certified public
accountants, I am seeing their use more frequently on
partial (residual) disability claims to dispute the pre-
and post-disability earnings figures provided by the claimant.
Sometimes the claimant’s CPA is overly aggressive
with respect to the filing of a tax return and deductions
are made that are not correct.
The partial disability claim takes longer
to agree upon with respect to the percentage the insurance
company requires to arrive at the amount of money to be
paid. There are times when a compromise will be made to
arrive at a figure acceptable to both parties.
In no event should a dentist discuss over
the telephone any calculations related to financials (tax
returns and so forth). The dentist should request that
the insurance company provide in writing any questions
it may have, which can then be reviewed by the dentist’s
accountant. The CPAs for both sides can then be in discussion
(but not the dentist).
How a disability claim is submitted from
a paperwork standpoint and how you act in your personal
life can determine whether you get paid by the insurance
company.
Most attending physicians do not know
the difference between a workers’ compensation claim,
a Social Security disability claim and your personal or
overhead disability policy(s) from a definition standpoint.
They physician might be given guidance in understanding
the significance of certain questions asked on the claim
form.
_____________________________________________________________
Art
Fries is a disability claim consultant providing advice
nationwide. He is located in Newport Beach, Calif. To
learn more about disability claims, call 800-567-1911
or visit www.afries.com
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