In our last post, we noted that dentists are much more likely to become disabled than other professionals. At the same time, dentists’ claims are often targeted for denial because they (1) have high benefit amounts and (2) usually involve occupation-related slowly progressive musculoskeletal conditions, which are much easier for the insurance companies to undercut.
As you might expect, when it comes down to it, the claims process is just a numbers game to insurers and, since the insurance company’s potential liability on a dentists’ claim is relatively high, dentists’ claims draw a lot of scrutiny. In an interview with Dateline NBC, a former Unum staff physician explained, “there was no concern for the individual. It was just bottom line. If we can terminate this file, we’re going to do it.”1 Once they’ve denied or terminated a claim, insurers have great power over a policyholder, because they have the time and resources to weather lawsuits without significant financial hardship. They bank on the fact that many policyholders are not financially, physically, or emotionally able to withstand a lengthy trial to contest an unfair denial, and seek to wear the policyholder down until the policyholder gives up or settles for much less than they are entitled to under their policy.
In a 60 Minutes interview (also discussing Unum’s egregious denial practices), former California Insurance Commissioner, and current U.S. Representative, John Garamendi explained it this way: “It’s an equation, an economic equation. ‘How many will we lose? How much business will we lose?’ Versus how much will we gain by denying these claims. So they’re doing that economic equation and saying we’ll run the risk of the lawsuit, we’ll run the risk of bad publicity and probably the departments of insurance are asleep anyway.”2 Unfortunately, although the departments of insurance were pretty active in the 1990’s and early 2000’s, they have greatly eased up their scrutiny in recent years. The insurance industry is monitored on the state level, so the amount of time, money, and resources devoted to investigations varies widely. Insurance companies know this and will often target and deny high-paying claims in states where the insurance commissioners are less likely to investigate allegations of improper behavior and/or states with case law that favors the insurer over the policyholder.
Insurance companies also target claims that involve slowly progressive conditions, like musculoskeletal conditions. These claims are much easier for the insurance company to undercut, due to the fact that proving up a musculoskeletal disorder and its full occupational impact is largely subjective. With these types of conditions, it is common for objective medical evidence (e.g. x-rays, MRIs, nerve conduction tests) to fail to conclusively document the source of a dentist’s pain and numbness, even if the pain and numbness is severe.
Even well-established testing, like MRIs, can be a double-edged sword. While in some cases, MRIs can help in pinpointing the problem for pain and, ideally, lead to effective treatment, they can also complicate a dentist’s disability claim because MRIs often fail to contain any conclusive findings that corroborate the levels of pain and/or numbness being reported. Further, not all MRI machines are created equal, and an older machine may yield different results than newer, more expensive versions. MRI results can also vary greatly depending on how the images are taken.
For example, in terms of musculoskeletal conditions, it is important that the images are angled to cut parallel to the disc space at each spinal level in order for the images to be helpful to a reviewing surgeon, but not all technicians know the importance of ensuring this is done.3 Similarly, while electromyograms and nerve conduction studies (EMG/NCV) are often employed to try to diagnose problems that occur in the peripheral nervous system, these types of tests can result in false positives/false negatives (particularly when pain and/or sensory changes develop from nerve compression without motor involvement).4
Insurance companies are aware of these limitations in medical science, and frequently challenge the claims of dentists who report debilitating neck and/or back pain. Companies often argue that, while an MRI may show disc problems, another person could have a similar MRI showing bulging or herniated discs and have no pain symptoms.5 Then, if no further steps are taken to get to the bottom of the source of the reported pain or numbness, the company’s in-house doctors suggest that degenerative changes are just a normal part of the aging process, conclude that the dentist’s subjective symptoms are not supported by objective evidence, and the company denies the dentist’s claim.
On top of all of this, dentists with musculoskeletal conditions frequently have to decide whether to undergo risky spinal surgeries or other invasive procedures. Along this road, they also reach a point where they must consider if they should continue working, just slow down at work, change the procedures they perform, and/or sell their practice. These treatment and career decisions, and their timing, can greatly affect the outcome of a dentist’s claim, and in some cases can foreclose the ability to collect total disability benefits (depending on the terms of the dentists’ policy).
Because of all of this, these claims must be handled with care from the outset, with the understanding that there will likely be significant pushback from the company. In later posts, we’ll provide some more detailed tips on how dentists can navigate the claims process effectively and avoid (or at least deal with) some of the challenges noted above.
Information offered purely for general informational purposes and not intended to create an attorney-client relationship. Anyone reading this post should not act on any information contained herein without seeking professional counsel from an attorney.
1. Dateline NBC: Benefit of Doubt (NBC television broadcast Oct. 13, 2002).
2. 60 Minutes: Not the Best Policy (CBS television broadcast Nov. 17, 2002).
3. Philip R. Shalen, MD, MRI Scan of the Spine, Spine-health, Dec. 20, 2002.
4. Donald Corenman, MD, DC, EMG/NCV – Electromyograms and Nerve Conduction Studies, The Steadman Clinic.
5. Back surgery: When is it a good idea?, Mayo Clinic.