Examples of Denied Claims for Disability Benefits
When dentists apply for disability benefits, they may not always receive coverage. In addition to reporting “a medical condition” and providing “statements from their physician(s) certifying disability,” dentists should provide detailed records of their tasks, proof of these fulfilled tasks, proof of earnings, etc., depending on the situation (Chmielarz 2015). Though, based on criteria stipulated in their policies, insurance companies may deny benefits to dentists for many reasons.
Policies deny coverage to dentists based on their rules and conditions. The application for policies determines whether or not a dentist will receive his or her benefits (Schneider 2008). For instance, if a disability is categorized as an exclusion, which was established at the time of the dentist’s application, then the dentist would receive a denied claim for that disability (Schneider 2008). Insurance companies could also deny claims if the elimination period (also known as waiting period), which is “the time that must elapse from the date the dentist first qualified as being disabled until benefits can be paid,” is not “satisfied, either due to the inadequate number of days, or days not being consecutive” (Biesterfelt 2010; Schneider 2008). If dentists do not report their disabilities within a specified time frame, insurance companies could deny them benefits (Gorman 2017). Also, the Definition of Total Disability will determine the dentists’ eligibility for coverage (Schneider 2008). For instance, an “own occupation, unable to work elsewhere” condition means that a dentist will receive benefits for approximately two to five years “so long as the insured can’t do the duties of their occupation even if the insured is working elsewhere so long as it is another occupation” (Schneider 2008). Afterwards, a dentist may continue to receive benefits if he or she is “unable to work elsewhere (by reason of education, training, experience, and sometimes prior economic status.)” (Schneider 2008). Though, Scott B. Gorman, “a founding member of the law firm of Gorman & Gorman,” states, “Many policies that insure professionals provide for benefits if the policyholder is partially disabled and earning less money than before the accident or illness occurred” (2017). The insurance companies will also “compare all of your medical records with your initial application for the disability policy” in a process of reverse underwriting (Gorman 2017). In order to deny claims, the companies must investigate if the dentists misrepresented their medical records (Gorman 2017). They also must determine “whether the misrepresentation would have affected the decision of the insurance company in issuing the policy in the first place, or in calculating the premiums” (Gorman 2017). However, if the dentists unintentionally did not give information, such as “occupation/duties” and “health,” that could affect the company’s decision to approve the claim, this action “might be ‘overlooked’ after two years, as outlined in the contract’s incontestability clause, unless there is other wording or state statutes to over-ride that clause” (Schneider 2008).
Dentists should read their policies in order to know their eligibility for coverage for certain disabilities.