Long-term Disability Claim Denials Pose Special Problems for Small Business Owners, Doctors, Dentists

The challenges that doctors, dentists, and others who own small businesses face if an insurance company denies a long-term disability claim are not unique. But such claims can play out differently from claims made by employees of medium and large companies with long-term disability insurance provided through their companies. The consequences may be especially devastating because of the nature of a solo practice or small business.

The good news is that the law has changed in Texas over the past few years, so that people whose claims were denied now have a much better chance of prevailing in court than they would have had as recently as three or four years ago. If your disability claim was denied, or payments were discontinued, it is important to speak with an experienced disability attorney as soon as possible.

If Your Long-Term Disability Claim Has Been Denied, Talk to Our Disability Attorneys

Our experienced disability attorneys may be able to help. We understand what it is like to be the “chief cook and bottle-washer” of your own business. Just as important, we understand the ins-and-outs of the various insurance policies purchased by many small business owners, professionals, doctors, dentists, and those offered by professional organizations.

If you want to know about long-term disability claims denial legal options, click this link Contact Kilgore & Kilgore to connect with us and get the conversation started. We offer a free evaluation of your case. To learn more about our disability claims denied law practice, click here Dallas Long Term Disability Insurance Lawyer – ERISA.

The Disability Claims Picture is Different for a Small Business and Small Office Practice

Running a doctor or dentist office or a small business hardly seems like dangerous work. After all, it is not like operating heavy machinery. But there are health risks, some of which can be disabling. Many of these disabilities are essentially invisible.

Dentists, for example, are particularly at risk for osteoarthritis and spondylosis of the elbow, neck, and other joints because of the amount of time that they spend standing or sitting in awkward positions. A severed finger that would be a nuisance to an investment advisor can end a doctor’s career.

Furthermore, as professionals and business owners who sell a service like medical care or some other personal service know, you ARE the product. If Mary Smith is a renowned dentist, the value of her reputation and skill is not transferable to anyone else. If she is unable to practice as a dentist, she loses her income. Without her, there is no small business. The whole edifice comes crashing down.

Where Disability Claims Go Wrong

There are a couple of inflection points where disability claims go awry. Sometimes insurers routinely deny claims based on certain diagnoses; fibromyalgia is notorious for this. The same is true for other conditions where the diagnosis depends on self-reported symptoms of pain or distress – like back injuries. Claims for mental health disorders are frequently denied, regardless of documentation.

Secondly, some disability insurance policies use one definition of disability for a preliminary period and another thereafter. Claimants may be entitled to disability payments for the first two years if they are unable to work in their own occupation – as a dentist, for example. Thereafter however, the dentist must demonstrate that he or she is unable to work in any occupation – as a medical coder, perhaps. That is known as the “own occupation/any occupation” turn where a lot of claimants lose benefits.

Finally, in some situations, insurers seek out evidence of a “primary occupation” and a “secondary occupation.” Suppose that Dr. Mary Smith, after patients were done and the receptionist went home, did the books and the billings. An insurance company might take this as evidence of Dr. Smith had a second job as a medical office administrator. That could reduce the payout on the loss of her dentist job.

But of course, as entrepreneurs know and as we understand, it is really all the same job.

Good Legal News from the Court

Until 2018, the rule in Texas, and throughout the Fifth Circuit, was that courts would review administrative decisions to deny long-term disability claims in ERISA plans only when those denials demonstrated an abuse of discretion. Courts used to give great deference to the decisions of plan administrators. Zipping past the legal history of the facts of the claim, the net effect was that long-term disability claimants who were denied benefits at the administrative level had little chance of success in court.

That changed in 2018 because of the Fifth Circuit’s decision in a case called Ariana M. v. Humana Health Plan of Texas, Inc. In that case, which involved a denial of health plan benefits rather than disability benefits, the Fifth Circuit overturned longstanding precedent and held that courts may reexamine the evidence afresh when the initial denial was based on a factual determination. In other words, now courts are not limited to looking for gross malpractice on the part of plan administrators. They can delve back into a claimant’s medical records to consider whether the denial was appropriate in the first case. In legal language, this is referred to as “de novo review.”

This decision brings the Fifth Circuit into line with other federal courts in the country. More importantly, it breathes new life into post-2018 ERISA lawsuits brought by individuals whose claims were denied. In 2019, in Pike v. Hartford Accident Ins. Co., the District Court for the Eastern District of Texas explicitly applied this new rule in a disability benefit denial lawsuit.

Our Disability Attorneys Can Help Professionals and Small Business Owners Whose Long-Term Disability Claims Have Been Wrongly Denied

We get what it is like to run your own medical care or dental practice or other small business, and we know the law. Our Texas disability attorneys can help you assess your situation and advise you on the best strategy. If you want legal advice about a denial of a long-term disability claim, or any other insurance benefit claim, we are here to talk to you. Click here to reach a form on our website to submit your contact information so we can get the conversation started Contact Us.

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