By Edward Dabdoub

Disability insurance is a complex area of the law. It is even more complicated when it involves an occupation specific definition of “disability,” like many physician disability insurance policies do. Two important aspects physicians should understand and keep in mind when thinking about disability insurance claims are: understanding the own occupation definition in your policy and knowing when to cut back versus stop working in your specialty.

Understanding “Own Occupation” in Your Disability Insurance Policy

One of the most important considerations of a disability insurance policy for physicians is the “own occupation” clause. In an individual disability policy, total disability is often defined by the physician’s ability to perform the “substantial and material duties” (or some similar terminology) of their own occupation. And own occupation is often uniquely defined to the specialty they are performing before they became disabled. So, this provision ensures that if a physician becomes disabled and is unable to perform the specific duties of their medical specialty, they will receive benefits even if they are capable of working in another occupation.

This is particularly important for physicians, whose skills and income potential are closely tied to their ability to perform highly specialized duties or duties that define their medical occupation. For example, in a case my law firm won a few years ago, our client was a liver transplant surgeon who injured his wrist in a fall and could no longer perform transplant surgery. His claim for total disability benefits was denied by his insurance company. The denial hinged on the interpretation of his specialty own occupation definition and how his occupation as a liver transplant surgeon is performed.

While he continued to perform other important job duties, including other types of general liver surgeries, it was agreed that he was unable to perform liver transplant surgery. Nevertheless, his insurance company claimed that he was not totally disabled from being a liver transplant surgeon because he could perform other duties, particularly nontransplant liver procedures.

We argued that liver transplant surgery is a unique medical specialty in that transplant surgeries do not occur every day and the majority of other duties make up other aspects of that occupation. Thus, it is customary for transplant surgeons to perform other types of general surgeries. But once a liver transplant surgeon can no longer perform liver transplant surgeries, they are disabled from that specialty. The court fully agreed and found our client totally disabled from his liver transplant occupation.

This legal reasoning can be applied to many other medical occupations and specialties, depending, of course, on the specific facts involved. But the main take away here is that insurance companies seek to broaden the scope of medical occupations to defeat claims for total disability whenever the physician continues to work in some capacity. Knowing how to navigate the claims process and framing the occupation therefore becomes incredibly important to securing the benefits the disability insurance policies were meant to provide.

Should I cut back at work or stop working entirely?

Timing is everything with disability insurance claims. Your occupation is defined by the duties you were performing just prior to leaving work due to your disability. For this reason, it is important not to erode your occupation by cutting back hours or reducing the number of procedures or surgeries you perform.

I often see situations where a surgeon, for example, knows her hands are becoming less functional, so she continuously scales back on the longer and/or more complex surgeries in the months (or sometimes even years) before she actually stops working. By the time she is ready to submit a total disability claim, the insurance company is looking at her surgical schedule and CPT codes in the months just prior to her last day at work to determine the nature and scope of her occupation.

A once thriving surgical practice that dominated the surgeon’s time and revenue generation may have dwindled down to a small fraction of a radically different looking job. In such a scenario, the insurance company may take the position that the material and substantial duty of her occupation was not how she performed her occupation over many years, but how she performed it just before she stopped practicing. Thus, this erosion of her occupation from surgeon to something else may result in a denial of disability benefits.

As a law firm specializing in disability insurance claims, we have represented physicians with this precise problem with successful outcomes. Still, the advice remains the same: get the timing right. If faced with a medical condition that impacts your ability to do your own occupation and deciding whether you should cut back on certain duties or stop working all together, it is important to consider how it will impact your disability claim and the presentation of your own occupational duties.

Edward Dabdoub is Founding Attorney of Dabdoub Law Firm. For more information, visit www.longtermdisability.net or call 1-888-812-0393.