Dentists’ claims for short-and long-term disability (STD and LTD, respectively) benefits are often among the most complex and difficult claims to get (and keep) approved, and also to successfully navigate appeals and lawsuits when they get denied. This article discusses why these types of claims are so difficult, and provides information about what dentists specifically should keep in mind when they are purchasing STD/LTD policies, applying for STD/LTD benefits, or facing a denial thereof.
If the topics discussed in this article seem relevant to your situation, it is wise to contact an attorney to discuss your particular situation in more detail.
Why are Dentists’ disability claims so likely to be denied?
Insurance companies’ business model relies on the core requirement that they bring in more money through premiums than they pay out in benefits. Thus, there are enormous financial incentives for insurance companies to deny as high a percentage of claims as possible. This fundamental aspect of the insurance industry certainly applies to the companies who offer short- and long-term disability insurance policies, such as Unum, The Hartford, Reliance, MetLife, Madison National Life, and others. So, it is just an unfortunate reality that insurance companies will try and deny as many claims as they can. This means that if an insurer thinks it can reasonably argue that a given injury, illness, or other medical condition does not prevent a policy-holder from performing their own or any occupation (depending on the policy’s definition of “disabled”), they will almost always try to deny that policy-holder’s claim.
Dentists’ STD/LTD claims are particularly tempting for insurance companies to deny. This is due to two main factors: first, the hyper-technical nature of dentists’ jobs makes their productive functionality particularly vulnerable to injuries that insurance companies consider to be “minor” and not sufficient to render someone unable to work; and second, the high dollar value of dentists’ STD/LTD benefits makes them more financially worthwhile for insurance companies to deny and then fight related appeals.
Regarding the first factor, dentists' vulnerability to minor injuries, this is because there are few professions where a minor finger injury can be the difference between expertly performing complex and highly technical procedures and being completely incapable of performing even the most basic job duties. Because of this vulnerability, insurers often discount the disabling impact of what they view as “minor” injuries which they do not believe should realistically prevent a dentist from performing their job duties. Thus, insurers are quick to deny dentist’s claims on the basis that their condition is not of the severity that would render them disabled.
Regarding the second factor, not all claims are created equal in the eyes of insurers. Because the value of STD and LTD benefits are a percentage of the policy-holder’s income, the higher the policy-holder’s income, the more expensive it is for the insurer to approve that policy-holder’s claim. Because dentists often have among the highest-paying insurance policies, a cost-benefit analysis would dictate that it makes more financial sense for an insurer to invest resources into fighting a dentist’s benefits claim than it does to fight a much lower-paying claim of the same merit.
Thus, for those reasons among others, dentists who file STD or LTD claims are particularly likely to have their claim denied, even if they are clearly unable to work.
Important considerations to be made when considering STD/LTD insurance policies and claims as a Dentist
There are many considerations that dentists should make when considering applying for STD/LTD benefits or appealing a denied claim. A few of the most crucial considerations are briefly discussed below.
- Did you purchase your STD/LTD policy individually or did you receive it through your employer? This will determine which law likely applies to your policy and any related claims, appeals, or lawsuits. The difference in applicable law has major implications for case strategy such as whether, when, and how to appeal a denial or file a lawsuit, how to engage in settlement negotiations, and what types of damages you can seek.
- Do you own your own practice? Then it may be worth looking into whether you also have overhead expense insurance along with your STD/LTD policies.
- How does your policy define “disabled”? Some policies pay benefits for as long as you are unable to perform the material job duties of your own occupation. However, some have a change in definition (typically after 24 months of disability) that means you need to show you are unable to perform any occupation.
- How are your “pre-disability earnings” calculated? Most plans calculate benefits owed as a percentage of the policy-holder’s “pre-disability earnings.” This means that the higher your pre-disability earnings are, the higher your benefits are. The way pre-disability earnings are calculated is particularly relevant to dentists and other individuals who have a high degree control over how much they work because in some situations, policy-holders who “taper down” their hours worked before ultimately ceasing work can inadvertently degrade the value of their STD/LTD benefits.
e..g. If a plan calculates pre-disability earnings based on the policy-holder’s average monthly income over the 12 months before they cease work altogether, and this particular policyholder had slowly decreased their hours from 40/week to 10/week over the last 12 months, their pre-disability earnings (and, by extension, their STD/LTD benefits would be lowered due to any decrease in pay associated with that decrease in hours. Whereas, if they had ceased working altogether a year earlier, or alternatively tapered more quickly over a period of just 6 months, their pre-disability earnings would not be as dramatically decreased.
What to do if your claim is denied?
If you are a dentist and your STD or LTD claim is denied, it is wise to contact an attorney experienced in handling STD and LTD cases. Typically, the next step after an unreasonable denial is to file an administrative appeal. It can be risky to attempt this appeal process on your own, particularly if your insurance policy is governed by ERISA. This is because under plans governed by ERISA, the administrative appeal process is your only opportunity to introduce additional information and evidence to support your appeal. If such an appeal is denied and you must file a lawsuit to recover benefits, the reviewing court will only consider the evidence submitted to the insurance company during the administrative process.
An experienced STD/LTD benefits attorney will be able to advise and/or assist you in navigating the often-times confusing application, appeal, and lawsuit stages of a STD or LTD benefits claim. Call Hawks Quindel to speak with a member of our STD/LTD team about your claim, whether dentist-related or not.