Group Disability Claims
Disability insurance plans designed for
ADA member dentists, and other group
LTD insurance plans, are generally reg-
ulated by federal law titled the Employ-
ees Retirement Income Securities Act
(ERISA). Under ERISA, state insurance
laws are preempted. To put it bluntly,
you are prevented from pursuing state
law procedures and remedies to protect
your rights.
To appeal a group disability claim denial,
you cannot immediately sue the company
to enforce your rights. You must first ex-
haust the insurance company’s internal
appeals process. Just like it sounds, this
appeal is often nothing more than an in-
ternal review with the same insurer that
denied the claim in the first place.
If the insurer continues to deny the
claim, you may then file a lawsuit in fed-
eral court. But here is the kicker: at this
point, ERISA law prohibits the admis-
sion of new evidence into the case. You
also have no rights to a jury trial to de-
cide your claim.
Under ERISA, you can only sue for what
the insurance carrier should have paid
you in the first place. As you might imag-
ine, in a system where the worst that
could happen to the insurance company
is that they have to pay the original claim
and nothing else, the insurance compa-
nies are emboldened to deny claims as
they see fit.
duced if the insurer says you only qualify
under the partial disability part of their
policy.
Do you have an “Own-Occupation” pol-
icy? Prevalent in most private disability
plans, “own occ” covera ge is occupation-
specific. The definition of disability re-
lates to your specific occupation or
Before you ever need to
file a disability claim, be
proactive.
sub-specialty rather than the broader
definition of “any occupation.” E.g., your
occupation is defined as “endodontist” or
“oral surgeon” rather than “dentist” or
“practicing dentistry.”
Conversely, group LTD policies are often
written as “any occupation” where it is
much harder to qualify for benefits. You
must prove you are unable to work in any
job that is reasonably suitable for you
based on such things as education, expe-
rience and age.
Before you ever need to file a disability
claim, Be proactive. Get a copy of your
disability policy, understand its terms
and definitions. With so much at stake,
have a plan in place if the day comes
when you must file a claim.
The reality is, paying high-dollar insur-
ance premiums for disability coverage is
a billion dollar business. The burden to
fortify your claim with great attention to
the smallest details will be yours.
Marc Whitehead, Esq. is the founding
partner of Marc Whitehead & Associates,
which he established in 1992 in Houston.
His firm specializes in disability law, and
he is a frequent lecturer on the topic.
Marc earned his undergraduate degree
from Texas A&M and his juris doctorate
from University of Houston. For more in-
formation, please call 713.228.8888.
Know Your Policy’s Terms
and Definitions
The language in your disability policy
can be the key to actually getting paid.
Terms and provisions used in a policy
are never accidental, and are just one
more way for insurance adjusters to limit
or deny coverage.
How your policy is written determines
how to develop your application for dis-
ability. For example, what is your policy
definition of total disability compared to
partial or residual disability? Even if you
are not totally disabled, by losing the
ability to handle routine dental proce-
dures, your income can be drastically re-
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