How to File a Disability Claim as a Physician: A Step-by-Step Guide to Navigating the Process
If you sustain a disabling illness or injury as a physician, you must file a claim with your insurance company, which is more than just a simple form.
Depending on your insurer, filing a claim and waiting for it to be approved or denied can take a few days or a few weeks — and it can be a stressful period.
To help you through it, here are the 11 steps to navigating the process when filing a claim for physician disability insurance benefits.
1. Call Your Insurance Company Right Away
When you should file a claim does not depend on the waiting period of your disability insurance policy.
Even if you have a long waiting period of 360 days or more, you must file your disability claim immediately. Some disability coverage policies require you to file a claim within 20 to 30 days from the date you incur your disability or receive a diagnosis.
As soon as your doctor says you will need to stay out of work on disability, get the ball rolling and contact your insurance company. Once you’ve reported that you will file a claim, the company will send you the relevant forms or tell you how to access them online.
Also, ask what supporting documentation you will need to provide, such as:
- Medical records
- Employer statements
- Results of medical exams
It may take some time to gather this information from the appropriate parties, so acting on this without delay is important.
Be sure to file all claimant forms and supply the insurer with all accompanying documentation before the filing deadlines. Any missed deadlines can adversely impact your ability to collect benefits, and could even result in your claim being denied.
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2. Obtain Your Medical Records
You’ll need to obtain multiple medical records and a doctor’s statement as medical evidence to support every short term or long term disability claim.
To collect disability benefits, you’ll need to prove that:
- You’ve suffered a disabling accident or illness.
- The disabling event will adversely impact your ability to practice medicine.
Insurers will require a written statement from your treating physician. This document will detail the nature of your injury or illness, describe the treatment plan, and verify that you either cannot work at all or will be limited in what tasks you can perform or how much time you can work.
The insurance company will also need records including medical history, physician notes, MRIs, X-rays, and lab reports.
Compiling all these documents and reports takes time, so be proactive and request the necessary records as soon as possible to ensure you don’t miss a filing deadline. Stay in close contact with your physician’s practice to ensure they provide you with the required documents promptly.
When you receive the documents from your physician, it’s a good idea for you, your attorney, and/or a trusted family member to review all the information provided. You can jeopardize or delay claim approval by providing documentation that isn’t 100% accurate or up-to-date.
3. Obtain a Statement From Your Employer
In addition to medical records and physician statements, your employer must also fill out a form for your insurance company.
They’ll need to disclose information regarding:
- The details and duties of your job
- Your salary
- How many hours per week you work
The insurance company needs this information to determine how much disability income you qualify for and what your monthly disability payments should be.
4. Check Your Policy’s Definition of Disability
Every disability insurance policy has a definition of disability, and you must meet that standard to be eligible to collect benefits.
The default definition for most insurers is “any-occupation,” meaning your injury must prohibit you from working in any job whatsoever.
Many employers that offer disability insurance for physicians usually offer a group policy with this definition. It can be quite challenging to qualify for benefits under this definition.
With an “own-occupation” definition, your policy will pay benefits if your injury prevents you from working at your current job in your medical specialty. This policy language makes it much easier to meet the eligibility requirements.
5. Check Your Policy for Exclusions
Before you make a disability insurance claim, review your policy to remind yourself what exclusions or limitations it contains. Your eligibility for benefits depends on all the agreed-upon terms, including what isn’t covered.
Disability insurers typically will not pay claims for an injury or illness resulting from:
- Self-inflicted acts
- Criminal activities
- Acts of war
- Civil disobedience or rebellion
- Operating a motor vehicle while intoxicated
Injuries resulting from participation in a potentially hazardous activity, such as skydiving or auto racing, may also make you ineligible to collect benefits. These are standard exclusions, and it’s easy to understand why they exist.
Aside from those standard exclusions, many policies have additional limitations that are specific to your underwriting.
These often restrict coverage for claims on a disabling condition resulting from or related to a pre-existing medical condition. If you have an excluded pre-existing condition and develop a new injury or illness, your physician can provide the insurer with medical evidence that shows that the two are unrelated.
6. Submit Records and Claim Forms on Time (and Keep Copies)
Be sure to provide your insurance company with any and all records and required forms in a timely manner — and always keep copies for yourself. When sending hard copy forms through the mail, note the date and time of each submission.
You should also save all email correspondence and keep notes of all phone discussions you have with the insurer, including the date, time, and who initiated contact. When talking over the phone, write down everything that was discussed between you and your agent or the insurance company representative.
Keep these records together in a safe place, along with your financial and medical records. These will be important should you ever need to file an appeal on a denied claim.
7. Determine If Your Injury Makes You Eligible for Partial or Residual Benefits
When diagnosed with an impairment rather than a total disability, it matters whether your policy covers residual or partial disability.
Residual disability is generally defined as being able to perform one or more (but not all) of the substantial and material duties of your occupation. It also describes being unable to work in your occupation for a set percentage of the time.
Residual disability benefits are triggered when the insured loses an established percentage of income because of their disability. The monthly benefit you receive under the provision is typically proportionate to your lost earning power, so you may only be eligible to receive a partial benefit to cover a percentage of your lost income.
Before you file a claim, have a discussion with your physician to determine if your injury will allow you to continue to work part-time in a diminished capacity, or if it will prevent you from working at all. The more direct you are in your claim, the easier it may be to get it approved.
8. Ask Your Insurance Company How Long the Claims Process Takes
Every long-term disability policy has its own terms, and every insurance company has its own procedures.
When you submit your forms, statements, and medical documents, confirm that they’ve been received and ask your carrier how long the claims approval process takes.
If they tell you the approval process takes two weeks and you’ve haven’t heard back from them by day 15, follow up with a phone call. While a shorter elimination period of 30 or 60 days may make this issue seem more pressing, it’s not. You should always confirm that your claim is approved within the insurer’s typical time frame, regardless of your elimination period.
9. Know What to Do If Your Insurance Company Denies Your Claim
Your claim may be more difficult to get approved if you have a policy with an “any-occupation” definition instead of one with the “true own-occupation” definition.
In some cases, it may even be denied.
If that happens, you can file an appeal, but you should seek the expertise of a disability attorney to help you do so. An appeal may require you to provide additional medical documentation or go to mediation or civil court for the benefits you think you deserve.
As a high-income earning physician, SSDI benefits through the Social Security Administration will not be nearly enough to cover your lost income. Social security disability insurance offered by the SSA has a maximum monthly benefit of $3,627 as of 2023, which is a fraction of what most physicians stand to collect in disability income insurance coverage.
Should your insurer deny your claim, you may have to fight a legal battle to receive the benefits you deserve.
10. Be Careful What You Say at All Times
As soon as you think you’ll need to file a claim, be careful what you say and who you say it to.
Should you have to enter into mediation or file a civil suit against the insurer, anything you’ve said publicly or to a third party could be used as evidence in favor of the insurance company.
Therefore, it’s best to limit discussions about your disability and avoid posting specific information on social media or public forums.
Perhaps more importantly, you should only provide the insurance company with the specific information they requested. Be honest at all times, but keep your answers short and to the point. Do not offer additional explanations or details unless they are specifically asked of you.
Anything you say or write can be used against you, even if it was misinterpreted.
While many people only retain an attorney after a claim has been denied, some physicians opt to hire one before they even file their initial claim. This is a good idea as an added measure of protection, as well as a way to ensure that all forms and statements are prepared and filed properly.
11. Don’t Forget About Your Riders
When your disability insurance company approves your claim, speak to them about any additional riders you have that might now kick in.
For example, if you’re paying for the student loan repayment rider to cover your medical student loan debt, make sure you know how and when student loan payments will be made. If you’ve paid for the waiver of premium rider, ask your insurance company when you can halt making monthly premium payments.
When your elimination period is nearing its end, contact your insurance provider to confirm that they are going to start issuing all these benefits.
You buy long term physician disability insurance hoping you never have to use it, but there may come a time when you’ll need what you’ve paid for.
It’s a good idea to review your policy every year to ensure that it still provides adequate coverage based on your current health conditions and salary. This is a good way to remind yourself of all the provisions your policy contains and take measures to protect yourself with more coverage if needed.