Private Disability Insurance Claims

Don’t accept a denied disability claim as a final decision.

Medical professionals appreciate the value of a comprehensive disability insurance policy. However, whether your policy is long-term, group or individual disability insurance policy, it might be necessary to work with an experienced legal professional to gain a clear understanding of your coverage.

Insurance carriers routinely include language in their policies designed to limit coverage in the event of a disability. For example, insurance companies may include a provision that a disabled person must first be receiving “appropriate care” for the condition causing the disability. It is how the insurance companies interpret the wording of “appropriate care” that has been the source of conflict between many claimants and their insurers.

Insurance Companies Word Policies In Attempt To Create Loopholes To Deny Disability Coverage

It is wise to have a knowledgeable lawyer at Donahue & Horrow, LLP, carefully review your policy before you ever have a claim. Insurance policies are historically complex and difficult to navigate. Our attorneys have a depth of knowledge and level of expertise necessary to navigate even the most complex insurance policies and explain them to our clients.

Heller v. Equitable Life Assurance Society of the United States, 833 F.2d 1253 (7th Cir. 1987) is a frequently cited case that involved a physician who filed a claim after being unable to perform invasive cardiology surgery due to carpal tunnel syndrome. Equitable Life Assurance held that Heller was not entitled to benefits because he had not had surgery for carpal tunnel syndrome. Heller’s policy only stated that he must be “under the regular care and attendance of a physician” for his disability and the court decided in Heller’s favor. As a result, disability insurance carriers have attempted to include stronger conditional clauses that would allow them even more leeway to deny benefits claims.

Medical professionals, as well as any professional, should strive to have a clear understanding of their disability coverage well in advance of the need to file a claim. By working proactively, we can alert doctors, dentists, surgeons and other medical professionals of any vague language or intentional complexities in a policy. If the need arises, it is wise to work with an experienced lawyer before you file a claim. We will provide valuable legal advice and diligent representation through the filing or appeals process if your claim is denied.

“Doctors, who buy more than their fair share of disability coverage, have historically made more claims than other white-collar professionals. In fact, doctors claim so much more that the odds for all other white-collar workers improve a few percentage points when physicians aren’t included.” New York Times

In Provident Life & Accident Ins. Co. v. Henry, 106 F.Supp.2d 1002 (C.D. Cal. 2000) the Ninth Circuit held that an insurer may include conditions for receiving disability benefits that require surgery as part of “appropriate care.” Henry, a podiatrist with carpal tunnel syndrome was under a physician’s care, but his claim for disability benefits was denied on the basis that he had not had surgery to attempt to correct his condition. Henry claimed the language in his policy did not make clear that he could be required to undergo surgery before being entitled to receive benefits. The court sided with Provident on the basis that, even when surgery was not specifically mentioned, noting that under some circumstances, appropriate treatment could be interpreted to include surgery.

Two Words Commonly Used To Deny Disability Claims — “Appropriate Care”

Many insurance dispute cases have come before California courts, and courts seem to support that “appropriate care” may, in certain circumstances require certain treatments, including surgery whether or not a specific treatment is clearly mentioned in the policy as a condition of receiving benefits. This is one of the many reasons why it is so important to hire an attorney who understands insurance company loopholes as well as complicated medical issues.

Insurance companies, left to make their own independent decisions without any accountability would unfairly deny even more disability claims by asserting their own positions on what constitutes “appropriate care.” But we know how to challenge disability claims that are wrongfully denied and are not afraid to take on insurance companies who disregard an individual claimant’s own physician’s treatment plan for a patient.

 

Call to Schedule You Free Consultation With a Los Angeles Disability Claims Lawyer

If you have a question regarding disability insurance claims for doctors, it is crucial to contact a skilled attorney at your earliest convenience. All cases are taken on a contingency basis, which means you pay nothing and we receive nothing unless you win your case by way of settlement or verdict. Call our Los Angeles area office toll free at 877-664-5407 or e-mail us to schedule a free consultation to discuss your case.