Our office regularly consults with physicians who are considering filing a disability claim under their private, “own occupation” policies. Most often, the physicians are dealing with a physical injury, or slowly progressive condition (like a tremor or degenerative disc disease) that has started to limit their ability to safely practice on patients. But we also speak with a considerable number of physicians who are struggling with mental health conditions and/or substance abuse.
When we ask them to tell us more about what is going on, the term “burnout” is often used to describe what is happening—likely because this is something that the physician has heard about since medical school, and because it is a convenient shorthand to describe a wide range of issues. And, in fact, some studies have created a structured definition of “burnout” and demonstrated a correlation between “burnout” and physician mistakes/sub-par care. However, there is a problem with using this particular terminology in the context of a disability claim.
Can You File a Disability Claim for “Burnout”?
The short answer is, if you file a disability claim and list “burnout” as your disabling condition, your claim will probably be denied. The primary problem with using the term “burnout” on disability claim forms is that it is a vague and amorphous term that can be manipulated by insurers seeking to save costs at your expense.
In our experience, when physicians use the term “burnout” on claim forms (prior to our involvement), insurance companies seek to trivialize and downplay what the physician is going through, and often maintain that the physician is just “stressed” or “hates his/her job,” has secondary motivations for leaving practice, and is not actually disabled. They know that many physicians are all too eager to talk about the demands of their job (particularly if they are under the impression that doing so will be helpful to their disability claim), so they purposely ask questions on claim forms and in interviews to elicit responses that shift the focus to what the physician didn’t like about his or her job, and away from any underlying mental health issues that the physician might actually be struggling with.
That being said, under most private disability policies sold to physicians, the insurance company is contractually obligated to pay benefits as long as you are unable to perform the “substantial and material duties” of your specific occupation. And under some policies, your occupation might be further defined as a particular medical specialty (e.g. anesthesiology or obstetrics). Thus, generally speaking, if you suffer from a legitimate condition that is interfering with your ability to practice medicine safely, you should be able to collect benefits—provided that you present your claim in the proper manner and your policy does not exclude or limit coverage for mental health condition (see below).
What Are Your Odds of Collecting if You File a Disability Claim?
In our experience, mental health and substance abuse claims can be some of the most difficult disability claims—particularly if they are not handled correctly from the start. The scope and depth of the insurance company’s investigation can become very invasive, if left unchecked, and it can be particularly hard for claimants dealing with mental health issues to have their private thoughts and struggles placed under a microscope and reviewed by strangers. In addition, policy provisions have evolved over time to contain increasingly complex and dense language, particularly when it comes to mental health claims. And many companies have even created special units made up of claims consultants and in-house psychiatrists and psychologists who are specifically trained to handle these types of claims.
While these challenges aren’t insurmountable, if you aren’t aware of them from the start, it is easy to make mistakes that can result in your benefits being delayed, or your claim being denied altogether. While each claim is unique, and the particular challenges you will face will in large part depend on factors such as your area of practice, your condition, your insurer, and the terms of your policy, here are a few of the common challenges that you should be aware of if you are a physician thinking about filing a mental health or substance abuse disability claim.
Challenge #1: Using the Correct Diagnosis on Claim Forms
When filing a claim based on a mental health condition, it is important to recognize that there are several degrees between ordinary stress and fatigue and a disabling condition, and where you fall on that scale is something that the insurance company can (and will) misconstrue, if you are not precise when reporting your conditions and limitations.
Thus, if you have a mental health condition and are thinking of filing disability claim, the first thing you should do, from a claims perspective, is consult with a mental health professional to determine whether or not you have a diagnosable condition. As certain aspects of burnout also overlap with symptoms of depression, anxiety disorder, and other mental health conditions, it is important to obtain a clinical diagnosis if you feel it is no longer safe for you to be practicing so that, when the time comes to file a claim, you will have a specific condition to report on the claim form and documentation to back up this diagnosis.
Challenge #2: Finding the Right Mental Health Provider
Most disability policies have care requirements that state you must be receiving ongoing treatment in order to remain eligible for benefits. In the context of mental health claims, some policies further require that you see a specific type of provider (e.g. a licensed, doctorate-level practitioner) in order to satisfy the care requirement of your policy.
With mental health conditions, it can take some time to find a provider with whom you can trust and feel comfortable. If you know your policy’s care requirements in advance, you can take it into account when selecting a provider, and find one that is in-line with the requirements of your disability policy. Conversely, if you don’t take the time to review you policy, you may be forced to start over from square one with a new provider in order to keep your benefits.
Challenge #3: Modifying Your Occupation
Many physicians feel pressure to push through mental health conditions, adjust their work schedule, and/or alter their responsibilities so that they can work as long as possible before filing a claim. However, this can result in the physician unknowingly prejudicing his or her ability to collect under their policy down the road. This is because under most disability policies, your occupation is defined by the occupational duties being performed immediately prior to the date of disability (as opposed to your occupation at the time the policy was purchased).
Consequently, taking extended leaves of absence, avoiding shifts, reducing the number of medical procedures you are performing, and/or transitioning into more of an administrative role (if that is an option for you) opens the door for your insurer to determine that you are a “part-time” physician who only performs certain procedures, or spends the majority of your time performing administrative tasks. This is significant because the list of “material duties” that involve patient safety becomes much shorter, which in turn can make it much more difficult for you to collect total disability benefits.
Similarly, many newer insurance policies now include language stating that if you are not working a specific number of hours per week outside the home (for example, 15 hours a week), you will be deemed “retired” or “unemployed.” These policies then go on to state that, if you are deemed “retired,” your duties will be defined as “the normal daily activities, including household duties, performed by the Insured at the time the Insured becomes disabled.” In other words, if this provision is applied, you must prove that you cannot perform the duties of a retired person in order to collect benefits.
Thus, delaying filing a claim not only puts your own well-being and the health of your patients at risk, but can also place your ability to collect disability benefits at risk.
Challenge #4: Substance Abuse and Mental Health Limitation Provisions
It is well documented that experiencing burnout can lead to mental health disorders, alcoholism, and/or drug addiction. In an effort to limit their liability for these types of claims, many insurers now place limitations upon how long policyholders can collect benefits for mental health or substance abuse claims, and some companies entirely exclude these sorts of claims from coverage.
In the past, these provisions were primarily found in employer-sponsored plans; however, they are now becoming increasingly common in private individual policies. Many private policies, especially newer ones, now also include provisions that limit the amount of time you can collect benefits for substance abuse or mental health conditions (usually to 24 months).
Obviously, it is important to know if your policy contains any limitations or exclusions before filing a mental health claim, so that you know what to expect and can plan accordingly. If you don’t take the time to carefully review your policy before filing, you can end up spending a lot of time and energy on a claim that ultimately will be denied if your policy does not actually provide coverage for mental health conditions or substance abuse.
Challenge #5: The Insurer’s Investigation
Many physicians are surprised by the scope of the claims investigation. Most physicians are unaware that insurance companies:
Begin investigating your claim as soon as you request claim forms. Many insurance companies require you to call the company to request the forms. This allows the insurance company to conduct an impromptu interview and to collect as much information as possible before you have a chance to see the claim forms, review the policy, or talk with an experienced disability insurance attorney to learn how the claims process works.
Speak with your treatment providers, family, friends and co-workers about your condition. The insurance company will have you sign authorizations that grant the insurance company sweeping authority to speak directly with a host of individuals (e.g. any provider you have ever been treated by, pharmacies, benefit plan administrators, insurance agents, financial institutions, the Social Security Administration, family, friends, co-workers and employees, among others).
Request a wide range of personal information. Most authorizations also allow the disability insurer to request virtually any information not otherwise barred by law–not just medical records. The information can also include prescription history, records for any substance abuse treatment, court records, occupational data, employment history, driving history, financial statements, and your earning history.
Schedule face-to-face interviews with you. Many insurers seek to interview you in your home, so that they can view your surroundings to see if they can find discrepancies in the claim, or learn more about you so that it is easier for them to conduct surveillance. These interviews can be stressful if you’ve never experienced them before, and they can be particularly difficult if you are expected to discuss your mental health condition(s) and the facts surrounding them with a complete stranger.
Order an In-Person Exam. The insurance company may claim that the exam is used to verify a disability; however, insurers also use these exams as a means to criticize your provider’s course of treatment, or dispute your provider’s conclusions and diagnoses. Most disability policies also provide that refusal to participate in an exam allows the insurance company to deny a claim or terminate benefits.
Use a private investigator to conduct surveillance. The insurance company may employ a private investigator to conduct photo, video and/or online surveillance, in an attempt to find discrepancies in your claim, or evidence of “malingering.” This can pose a particular challenge for mental health claims, as your symptoms may be greatly alleviated once you step away from practicing medicine.
If you have never experienced the claim process before, it can be hard to tell whether your insurer is taking things too far. While the investigation tactics discussed above are not per se bad faith, they are also not necessarily appropriate in every claim and, with mental health claims in particular, it can be important to draw reasonable boundaries so that the investigation does not interfere with the policyholder’s treatment. If you feel your insurance company is being too aggressive, an experienced disability insurance attorney can assess the scope of the investigation and whether the insurer’s conduct is proper.
In sum, physicians attempting to push through serious mental health conditions pose a risk to themselves and their patients, and oftentimes are just making it more difficult for them to collect if they decide to file a disability claim in the future. Conversely, if physicians suffering from these conditions file a disability claim in an informed manner, this can allow them to remove themselves from a bad environment and focus on their treatment, without further risk to their patients or own well-being.
While filing a claim is not necessarily the best option for everyone, if you find yourself struggling with a mental health condition and are trying to determine what to do, at a minimum, you should contact Benefit Representatives of America at (585) 663-6333 to find out if filing a claim is an option for you.