By Art Fries, RHU
Were you or another dentist you know among those who had filed a disability claim, and then coronavirus hit? The pandemic has presented problems for disability claimants and insurance company claim departments alike. How were dentists’ claims determined in the midst of office closures? What did insurance companies do to determine what dentists with disability claims received after their loss of income due to the shutdown? It’s a confusing time for all.
Claimants were sent into a bit of a tailspin during the uncertain times, no doubt adding to their stress of already losing work due to their disability claim, and then having to shut down due to COVID-19. Many have been in search of answers to their disability claims ever since. What can they do to get answers, and also, to present their claims in a more timely fashion to their insurance company’s claim departments?
Determining payment
To make a claim, someone must have medical issues that affect their ability to practice at their normal full-time schedule. Some companies look at whether it takes a claimant longer to perform his or her duties, and they do not include hours or elimination of duties, while others look at a 25%, 20%, or 15% loss of earnings and may or may not mention a loss of time or duties.
Partial, or residual, claims are computed by comparing predisability earnings to post-disability earnings. Some companies go back 12 months, some consider two out of three consecutive tax years, and some two out of the past five consecutive tax years to determine the claim. Often when a dentist reduces hours or eliminates some procedures, the gross collected fees are reduced, and earnings are reduced.
During the shutdown many practices did not make any money. Using a residual formula, there was typically a loss of earnings of 75%, 80%, or 85%. This would enable a clamant to collect 100% of the monthly benefit. However, the reduction in earnings was not related to the medical issue but to a state mandate that stated dentists could only service emergency patients. This posed a dilemma for both the insurance companies and claimants. What was fair? Should the insurance company pay 100%? Should they pay nothing? Should they pay something?
The answers to these questions eventually surfaced, and they were different for different companies. (1) The monthly benefit was paid based on the actual post-disability earnings submitted to the insurance company, even though these were caused by the state mandate. (2) A company used the same policy formula for predisability earnings and used an average of three months’ earnings prior to the mandate as the post-disability earnings figure rather than the actual figures caused by the mandate. (3) An average of six months’ prior earnings was used (prior to state mandate) as the post-disability earnings figure.
Other issues arose relating to the state mandate. Was a total disability claim submitted because the dental office was not making any money? Why didn’t the dentist submit a claim for total disability before the virus and state mandate? These and other questions were being faced by claim departments and there were no clear-cut answers. I even saw some claim handlers trying to blame entire claims on the coronavirus with the purpose of trying to get out of paying a legitimate claim.
After seeing this, my advice to dentist clients was to wait before submitting a claim until they were able to get their office running again and could build up their patient load and get their accounts receivable built up and the cash flow back to normal.
By working fewer hours or not working clinically at all for several months due to the state mandate, many of my dentist clients began to feel better with their medical issues, such as hand, neck, shoulder, and low-back pain. Whereas they had been planning to go on total disability, they decided to return to work because they felt better, yet returned to the normal daily grind that had brought about their medical issues in the first place.
Whereas before, many were in denial and loved their profession and their “identity,” then their new and limited hours that resulted from the shutdown gave them clarity that their medical issues were very real. While their claim became clearer to them from a claimant standpoint, the insurance company claim departments were questioning more closely why dentists were claiming total disability.
Insurance companies will be looking more closely at disability claims after coronavirus has peaked since some dentists will have further insights into their new lifestyle after spending more time off from work and experiencing less stress. Some dentists may come to appreciate a way of life that was not even in their thoughts prior to the virus. Many will decide to no longer work in pain and may stop working earlier than anticipated.
Preparing for an insurance company
Presenting a claim to the insurance company will require a great deal of expertise and clarity on the part of the claimant. These are very trying times for claim departments. Because many claim handlers are working from home, it is taking longer for them to respond to claimants. What had been considered routine in the way of field visits to claimants, examinations of claimants, or testing of claimants (where permitted) was put on hold because of the virus and those areas were causing a delay in claim departments approving or denying claims.
Things have gone back to somewhat normal in recent months and will continue to improve. That said, another state mandate could quickly change that.
Indeed, the system has been stressed on both ends. This will eventually change. In the meantime, if you are thinking about going on either a partial or total disability claim, you should seek advice early from those who specialize in this area. It is difficult enough to handle a disability claim by yourself but now, with the added issue of the coronavirus, advice becomes paramount to the successful outcome of a disability claim.
ART FRIES, RHU, is a disability claim consultant providing advice on a national basis in the U.S. He is located in Nipomo, California. He can be reached at (800) 567-1911 or [email protected]. Visit afries.com.
