Can Physicians Collect Disability Benefits for “Burnout?”

by | Published on Dec 24, 2018 | Social Security Disability

As a provider of medical review services for disability attorneys, we have noticed the alarming trend of an increasing number of doctors suffering from the effects of “burnout.” Such doctors tend to be dissatisfied with their profession and become incapable of functioning efficiently or dealing with their patients. Many such physicians file disability claims under their own private health insurance policies. The majority of disability claims filed are for physical injuries and various degenerative conditions that limit their ability to practice medicine, claims are also filed for mental health conditions and addiction/substance abuse. Physicians use the term “burnout” to describe the mental apathy they experience, and the term is now being used for a wide range of health issues.

What causes “burnout?”

  • Compared to the situation a decade or two decades back, physicians are working much harder.
  • Physicians are being victimized by business buyouts, acquisitions, and mergers.
  • With increasing health awareness and improved healthcare solutions, physicians have to see larger numbers of patients in less time.
  • Medical chart preparation and record keeping have become more complex.
  • With more time spent on the EHR, the physician-patient relationship is not as warm as it was before.

Can a physician file a disability claim for burnout?

Physicians are very likely to have their claim denied if they cite “burnout” as their disabling condition. Usually insurance companies play down the distressing experience of the physician and hold that the physician is either stressed out or does not like his/her job; or maybe is planning to leave the practice and is not actually disabled. Professional apathy alone is not considered a disabling medical condition and a disability insurance company will not accept “burnout” as a disabling condition that is compensable.

Physicians experiencing burnout, mental illness, addiction etc. can use their “own occupation” disability insurance as a tool in their own treatment and get back their health. There is always the possibility that claims may be denied. How can they avoid claim denials?

  • The basic medical symptoms or conditions that are caused by burnout must be documented and established. A number of health problems such as depression, insomnia, anxiety, cognitive difficulties, fatigue, substance use disorders and disruptive/performance related issues are caused by burnout and these can be substantiated via a medical chart review.
  • Make sure to use the correct diagnosis on claim forms. If you have a burnout issue, obtain a clinical diagnosis to establish it is no longer safe for you to be practicing. This ensures that when you have to file a claim, you will have a specific condition to report on the claim form as well as documentation to support the diagnosis.
  • Do not modify the way you work or your job. Often, physicians experiencing some form of burnout try to modify their work schedule or their responsibilities to try and work for a longer period before filing a claim. They may take long leaves of absence, perform lesser number of procedures, or take on more administrative duties. But this could have a negative effect – the insurer may form the idea that such a physician is a “part-time physician” or one who performs more of administrative jobs. This in turn would reduce your chances of collecting disability benefits. The insurance policy may contain language saying that if the physician is not working a specific number of hours per week outside the home, he/she will be considered retired or unemployed. For an insured physician considered as retired, the duties are usually defined as normal daily activities, including household duties performed by him/her at the time he/she becomes disabled. If this provision is applied, the insured physician has to prove that he/she cannot perform the duties of a retired person in order to collect disability benefits.
  • Review the insurance policy carefully to find out if there are any exclusions or limitations. Only if you know this, you can plan accordingly. If your policy does not provide coverage for mental health conditions or substance abuse, you will be wasting a lot of time and energy on a claim that may be denied ultimately. Another thing to look for is whether the disability policy has care requirements that state you must be receiving ongoing treatment to be eligible for the benefits. Sometimes, the policy may insist that you see a particular type of provider such as a licensed, doctorate-level practitioner.
  • Understand the nature of your insurer’s investigation. To avoid being surprised by the various ways in which insurers investigate your claim, be aware of the following.
    • Insurers would begin investigating the claim as soon as an applicant requests claim forms.
    • They would communicate with your treatment providers, family, friends and colleagues and make queries about your condition.
    • They would request a vast range of information regarding you, apart from medical records. This could include prescription history; records for substance abuse treatment, if any; court records; job data; employment history; financial history and earning history.
    • Schedule direct interviews with you. Insurers may ask to conduct interviews in your home to see your surroundings and determine whether there are any discrepancies in the claim.
    • Sometimes insurers may order an in-person exam. Apart from using such an exam to verify your disability, insurers may use it to censure your provider’s treatment protocol or counter your provider’s diagnoses and conclusions. Participation in the interview is mandatory, or the insurer has the right to deny your claim.
    • Insurers may employ a private investigator to conduct photo, video, or online surveillance with a view to find discrepancies in the claim or any proof of “malingering.”

Medical chart review is an important procedure in the disability determination process. In most private disability policies sold to physicians, the insurer is contractually obligated to pay benefits as long as the physician is unable to perform the “substantial and material duties” of his/her specific occupation. When filing a claim, make sure that it is presented in the proper manner and that the policy does not exclude or limit coverage for mental health conditions.

Disclaimer: The content in this blog has been sourced from various reliable internet sources and is for informative purposes only. It doesn’t constitute professional legal opinion. For professional legal counsel on the topic, consult an experienced lawyer.

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