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Disability Case Spotlight: Considerations for Determining the Initiation Date of Disability To Maximize Benefits

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By Bonny G. Rafel, LLC – Of Counsel

This is the first in a series of articles designed to showcase various topics related to disability claims that are particularly relevant to medical professionals.  When a client seeks our assistance regarding their need to file a disability claim under an insurance policy, we first determine when they became disabled. If the disabling medical condition is caused by a sudden accident or injury the date of disability is usually clear. Often the disability is instead caused by a progressive illness or condition that was initially manageable but became more limiting over time. Some examples of these long term conditions may be Multiple Sclerosis, herniated discs in the neck or low back, essential tremors or arthritis.

Most professionals will attempt to make accommodations or adjustments to their practice in order to remain at work as long as they can before beginning the process to file a disability claim. Steps taken might include relinquishing certain work duties/procedures that exacerbate the condition, reducing or eliminating hospital or emergency call, and reducing patient care hours. The medical professional may refer difficult cases out to other colleagues. These are all prudent and reasonable accommodations to make but they often lead to a significant loss of income over time.

Stoic individuals that continue to work despite brewing disability are essentially “working while disabled.” In these instances, we take the time to determine when exactly the disability began, and when did it interfere with the established duties of the occupation. The reason for this analysis is to evaluate whether we can date the claim to a time period even before the client meets with us. Why does this matter? Three incentives: establish a claim earlier so the waiting period for benefits has already occurred; establish a loss of earnings from the “working while disabled” period of time so that benefits can begin; and thirdly establish a basis for calculating a loss of earnings when the professional was earning the most in his/her profession.

By way of example, I provide information gleaned from recent cases we have handled. For example, a medical professional had developed a neurological condition causing tremors in both of his hands and arthritic changes affecting his dexterity.  At our initial meeting, he expected to file the claim some time in the future, but he had recently already given up much of his work duties and reduced his hours to a part-time schedule. His disability insurance policy included coverage for partial disability if his reduced work capacity was the result of his medical condition. We collected relevant data to analyze his duties, the change of duties necessitated by his medical condition, and loss of income. It seemed clear to us that he was in fact already “working while disabled.” Three categories of documents were needed to establish that his condition was impairing his work ability.  In this article, we cover the “financial evidence” and the “medical evidence, and follow with an article on the “occupational evidence” in detail. Every case has its own challenges along the way and below we highlight a few of the key factors.

Financial Evidence Needed for Success- In any case, we need to confirm our client’s earnings before the start of disability, through tax returns and documentation of average monthly income. Some clients are self- employed, and lack financial software such as QuickBooks that can generate monthly reports. An option thus would be to assemble records the professional’s medical billing company and then create our own income and expense spreadsheets. This information is crucial to establish the significant income decline or losses in the months the professional was working while impaired.

Medical Evidence- What Do The Medical Records Show Regarding Initial Impairment  The insurance policies require the insured be under regular medical care for the disabling condition at the time disability is alleged. In a recent case, a delay in coming under medical care pushed the start date of disability over a time-sensitive threshold, thus limiting our client’s lifetime benefits. Aside from a visit with a medical professional, remaining on medication is helpful to establish the timing of the claim. It is important to discuss work difficulties with some medical professional. But be careful, because if the professional advises his doctor that he is having difficulty performing his duties, what if a patient under his care alleges that he should not have performed the procedure? There is a fine line to walk in these circumstances. When our client declares themselves limited in work ability, we counsel them to stop performing procedures that are impacted by the impairment.

Submission of The Claim- We submit the comprehensive claim submission for our clients, explaining our client’s specialty occupation and how the evidence proves his/her case.  We endeavor to provide the insurance companies with all the proof they need to say “Yes” without protracted delays.

There are decisions to make when a disabling condition emerges, we often are able to initiate a disability before our clients initially thought possible, thus obtaining benefits for them sooner than they expected. If you or someone you know is in a similar situation we would welcome the chance to speak with you and work with you to get the outcome you deserve.