There is no easy answer to this question because disability insurance is as complicated as any other question where medicine and law converge. Only doctors, physical therapists, and other medical professionals are qualified to give a medical diagnosis to their patients. Likewise, only lawyers who practice disability law are qualified to determine whether a patient meets the legal requirements to receive disability insurance benefits.
Disability insurance laws represent a web of intricate legal definitions combined with individual circumstances reflecting the patient’s present and future physical or mental condition.
Even within the disability insurance context, there are state laws that govern individual private disability insurance policies that differ from federal laws governing group disability insurance policies under ERISA. There are also differences in disability law from state to state and even, at the local courthouse level, depending on how each judge interprets the law.
If that weren’t enough to make your head spin, did you know that a patient’s medical condition is just ONE of many factors that determine ‘legal’ disability?
Disability is determined based on your patient’s age, education, work experience, medical impairment, whether the claim is for social security disability or disability insurance and the definition of disability in the insurance policy. Whew!
Here’s one example of a patient you may have seen in your practice whose initial assessment about whether he could be qualified for disability insurance wasn’t an open and close case.
Recently, I consulted with an emergency room physician with hip dysplasia. His hip dysplasia was so painful it was making it more and more difficult for him to respond to emergencies. Because of the ER doctor’s young age, his orthopedic surgeon recommended he find another area of practice so that he could preserve the remaining cartilage in his hip and delay hip replacement as long as possible.
He does and he doesn’t.
Specifically, he does not qualify for Social Security Disability Insurance or SSDI because under SSDI rules and regulations, the ER doctor can perform other types of work available in the general economy. Case dismissed. No SSDI for this young ER doctor.
However, during my review of his private insurance policies, I discovered he had purchased an occupation policy and within that policy, he had smartly purchased a rider for his specialty as an ER physician. Under the definition of the ER doctor’s personal occupation policy, along with the nature of his medical impairment, he would undoubtedly qualify for benefits under his private disability insurance.
If your patient has a serious medical impairment, then it is prudent to refer to a disability insurance attorney because only these experts can assess all of the factors – medical, vocational and legal – to determine whether or not your patient qualifies for benefits under a group disability insurance policy through ERISA, Social Security Disability, or their own personal disability insurance policies. Why? Because it’s complicated!
