Professional Disability Claims/Bad Faith

Who We Help

For nearly three decades, Ed Comitz has developed a niche practice exclusively representing professionals – primarily physicians, dentists, other attorneys and business executives – filing disability claims under “own occupation” and “specialty-specific” disability insurance policies.

Many of Comitz’s clients come to him because they have the types of nuanced claims that insurers typically challenge, such as:

  • Mental-health conditions (e.g. depression, anxiety, panic disorder, PTSD),
  • Conditions with symptoms that are largely subjectively reported (e.g. musculoskeletal conditions, carpal tunnel syndrom/ulnar neuropathy, Rheumatoid Arthritis, pain-related syndromes, tinnitus, vestibular migraine, POTS),
  • Conditions where the severity of symptoms and progression vary from patient to patient (e.g. cervical and lumbar degenerative disc disease, herniated discs, spondylosis, spinal stenosis, neurological disorders), or
  • Conditions that are largely diagnosed by exclusion, through differential diagnoses (e.g. POTS, stroke, Crohn’s disease, cognitive disorders).

Some have conditions that are exacerbated by their workplace environment, but they are able to manage their symptoms if, for example, they no longer have to practice dentistry or hold static positions for hours as an orthopedic surgeon.  Others involve very discrete issues, like an essential tremor, neuropathy, the partial amputation of a finger, or a neuroma, that significantly impact the clients’ ability to safely practice their “own occupation” but do not prevent them from performing the activities of daily living, certain recreational activities or other jobs.

Filing a Claim

As a professional facing a disability, you likely have questions. Can I handle the claim myself, or do I need to hire an attorney? Will it be difficult to collect benefits?  How can I avoid making mistakes that could jeopardize my right to collect benefits?

Unfortunately, collecting benefits on a professional disability policy can be difficult.  As you might imagine, there is a lot of money at stake and insurance companies are motivated to boost their bottom lines by not paying claims.

Physicians, dentists and other professionals are typically not trained in law or insurance, and disability companies take advantage of this. Many professionals also do not realize that, in addition to the claims analyst, their insurance company has a team of lawyers, physicians, defense medical examiners, vocational and functional capacity consultants, surveillance personnel, accountants and others working behind the scenes to find ways to limit, deny or terminate benefits.  Indeed, the administration and termination of professional disability insurance claims is a billion-dollar business with increased focus on initial claim denials, limiting claim duration and focusing on return to work.

At the same time, dealing with a disability while transitioning out of practice is taxing—physically, emotionally and financially. It is a stressful time, and the last thing  you want to do is prejudice your rights.

Collecting Benefits

Unlike other types of insurance, disability claims are subject to ongoing evaluation and scrutiny. Given the potential duration of claims and amount of money at stake, professional disability insurance companies are often investigated and sanctioned by regulators for engaging in systemic unfair claims practices, including improperly targeting and terminating high-dollar claims. For example:

  • Multistate Market Conduct Examination of Unum Corporation:  Finding that Unum (including Paul Revere, Provident and other affiliates) had excessively relied upon biased in-house medical professionals and ignored the opinions of treating doctors; and purposefully cherry-picked and misinterpreted medical notes, attending physician reports and medical evaluation reports.
  • Massachusetts Market Conduct Examination of Guardian:  Finding that Guardian had failed to timely process claims; failed to properly document claim files; and miscalculated benefit amounts.
  • Maryland Insurance Administration’s Order regarding Berkshire:  Finding that Guardian affiliate, Berkshire Life Insurance Company’s claim forms invited ambiguous and misleading responses from the insured;  actions on claim amounted to “artful neglect” designed to not pay benefits due to insured; company gave “the appearance of investigating a claim in order to render a good faith claims determination. . . . In direct contrast to this ‘appearance,’ however, Berkshire [did] not analyze the information at all, much less use an analysis in a cogent and rational way to support a proper claims determination.”
  • California Market Conduct Examination of Metropolitan Life Insurance Company: Finding that Met Life made disability determinations without first requesting medical information from treating providers; repeatedly requested information that had already been provided by the claimant; improperly denied claims based on its own estimated return to work date, rather than the claimant’s actual ability to return to work; and misrepresented insurance policies to assert offsets that were not supported by the policy language.
  • California Market Conduct Examination of Unum Corporation:  Finding that Unum and its affiliates had purposefully cut short claim investigations in instances where further investigation could have secured information that would have supported a claim approval; inaccurately characterized the occupational duties of several professions (specifically nursing and medical/dental specialties); improperly evaluated “own occupation” claims; misrepresented policy provisions to claimants; and ignored medical opinions from its own doctors recommending claim approval.

In today’s uncertain economic climate, with fewer professionals buying disability insurance, many disability insurance companies are merging, facing pressure to reduce reserves or going out of business altogether. Unfortunately, this creates incentives to reduce losses by denying or terminating legitimate claims.

Insurers unfortunately continue to lob a seemingly endless barrage of obstacles at claimants, including: (1) video surveillance; (2) unannounced interviews; (3) in-house medical evaluations; (4) defense medical exams; (5) financial and insurance audits; (6) re-evaluation of answers on application forms; and (7) investigations of prior litigation and board complaints, as well as a wide variety of other tactics, some of which are discussed above, all aimed at increasing their bottom line.

How We Help

Our firm’s job is to even the playing field, and to make sure you are paid the benefits you are entitled to under your policies. While we do handle claims that have already been wrongfully denied or are being targeted for termination, ideally, we consult with doctors and other professionals from the time they realize that they may need to submit a claim. We determine whether you have a valid claim and identify issues that you may run into when filing. In situations involving slowly progressive conditions, we determine when it is appropriate to file for benefits and work with you to prepare a plan for your eventual transition out of practice, taking into account your particular circumstances and the requirements of your policies.

When it comes time to file, we handle all aspects of the claim. We require that your carrier coordinate all requests for information through our firm, so that we can monitor the requests and ensure that they are warranted and appropriately carried out. When your carrier requires interviews (of yourself, your employer, your staff and others), Independent Medical Exams (IMEs), Functional Capacity Exams (FCEs), or other examinations, our firm ensures that their representatives do not engage in improper questioning or insurance bad faith. We then monitor each disability claim and utilize our extensive industry knowledge to preemptively identify, document, and combat the insurance companies’ improper, bad-faith tactics, including improper and intrusive surveillance, before these tactics result in a claim denial or termination.

We also offer powerful strategies for healthcare and business professionals whose disability insurance companies have wrongfully denied their claims or attempted to stop paying benefits.  Litigating and resolving insurance bad-faith claims requires not only knowledge of the complexities of the underlying substantive law, but a recognition of the tactics employed by key participants in the disability insurance industry.  Knowledge of our opponents’ strengths, weaknesses and litigation styles has proven to be extremely beneficial to our clients, earning us a national reputation for results in this industry.

Our law firm is not afraid of a challenge. With decades of experience successfully handling some of the most difficult disability insurance claims, we work tirelessly to secure, protect and preserve the benefits our clients are entitled to receive under their policies.  For more information about this practice area, please visit www.disabilitycounsel.net