residual disability benefits This is a topic that many people are looking for. khurak.net is a channel providing useful information about learning, life, digital marketing and online courses …. it will help you have an overview and solid multi-faceted knowledge . Today, khurak.net would like to introduce to you Common Issues with Total v. Residual Disability Benefit Claims. Following along are instructions in the video below:
“I m greg dell. Here with cesar gaviria and today we re going to talk talk about a real common issue that we re seeing and that we ve seen ton over the last 10 years dealing with total versus residual disability and usually we only see this analysis come about in the private disability insurance policies not so much in the erisa group policies all of sometimes you can have a partial versus total claim and usually a lot of the total versus residual also known as partial disability claims that we see come about for physicians. Primarily so these are know recently in preparation for a national lecture. That you and i will be doing coming up soon you researched a bunch of cases to discuss this issue.
But for our purposes. And to make this topic. Pretty basic for someone who s watching this video let s first establish the two different types of definition of disability that we re talking about and then we ll use an example of a particular occupation like maybe. An interventional cardiologist or interventional radiologist to explain how it could affect that particular person.
So let s start with the the two types of definitions disability. That we re dealing with yeah and basically those are the the most common definitions of disability that we see in the individual disability policies. Which is total disability versus residual disability. And and the term of own occupation.
Okay and total disability in these policies are often defined as your inability to perform the substantial material duties of your own occupation. While partial or residual disability is defined as being unable to perform one or more of the substantial material duties of your own occupation and then they throw an income qualifier in there which basically says that in order to qualify you have to have at least a 20 loss of earnings. So those are the two most common definitions or terms that we find when doing that analysis right and so the conflict and the challenge that always comes in in these claims is often you have a carer who says we don t think your total. We think your residual because you can do one of the duties.
Whereas if you have five particular major using your occupation and you can t do four of them. But you can do one of them then they say your residual right not total so let s talk about a case that you recently read and and how that applied and what the court did in that situation. So we can give us the factual background and then well. I ll give you there s a case.
Actually in our home circuit. Here of the eleventh circuit. Where florida is that was actually a georgia case originally and it went through the course of going to trial and going through motions and all of that and then it finally ended up many years later in the appellate court at the eleventh circuit. And it was there mainly on this issue on the issue of total versus.
And the case. Is called gibbons. Vs. Equitable.
And dr. Gibbons was formerly a dentist. He had given up his practice actually interesting about four years before he claimed disability and at the time he claimed disability. He was claiming it as a as a dentist and as a real estate developer.
One of the issues before the court in that case was well what was his occupation. He was arguing that well my occupation is both dentist and real estate developer on that issue. The court said no it s very clear. There s no ambiguity here with respect to that the question of whether you re a dentist and a real estate developer.
You were not performing the material duties of a dentist at the time that you became disabled you were you know you had voluntarily or i guess you could say you had given up those duties in that occupation years before so. The question here is simply are you disabled or totally disabled. Or partially disabled from being a real estate developer and the court went through an analysis of whether he was totally or partially disabled from being a real estate developer. Inequitable was of course arguing.
Well if he could perform any of the duties of his occupation. Then at best. He s residually or partially disabled. He s he s i guess able to earn some income there whether he quality depending on what his income is he would qualify for a percentage of his benefit and since he s able to perform one or more.
He s partially disabled giddens was arguing doctor. Didn t was arguing that it really didn t matter. If he was able to perform one or more it depends performing and the ability to i guess really provide quality type of work in that occupation and in a way almost almost participate in that occupation with some continuity right and the court actually agreed with him in that case where they said look it it does come down to the quality of your occupation to essentially work. And not be able to earn any income and that occupation that in and of itself isn t gonna isn t going to mean you re partially disabled that could mean you re totally disabled.
And that s what the court ruled there so souter let s talk about an example like we said earlier..
We would talk about like an interventional cardiologist. So we ve had so many cases where potential client calls us and says look carriers telling me i m residual. I m telling them total and what s your occupation. I m an interventional cardiologist.
Okay well how often are you in the cat lab. Right wonder how much of your work. Is interventional. Cardiology or are you running the cardiac practice.
So first thing off it s not about what you call yourself you might call yourself interventional cardiologist. The title doesn t matter. It s all about what your cpt productions and your oh our cath lab stats are going to show so you ve had the scenario where the person says i m interventional cardiologist and they do two procedures. A week make 15 of the revenue from cat procedures and the other 85 is from office visits well that s probably that s a residual person because they re not really truly an interventional cardiologist.
As opposed to the person who makes seventy five percent of their revenue. Doing interventional cardiology cat procedures. The other 25 is incidental to going into the you know to be evaluated to see whether or not they need zatia so. But where is that line so there s a big gray area yeah because in those in the scenarios.
You just talked about that s almost like the no brainer. I almost know the the the easy scenario to figure out so what happens. When 50 percent or other procedures are interventional procedures right well 50 percent are office visits. But then say 25 of those office visits or that clinical work is incidental to the interventional or maybe even a greater percentage.
Right and then the other you know let s say half of that is you know general cardiology or whatever so it makes up for like 10 to 15 as being general cardiology. Now certainly you can t expect that if that doctor changes its practice completely that he s not going to make some profit and the insurance companies probably had gonna have a very hard time that if that doctor you know paying that doctor total. If he changes essentially his occupation from interventional to general cardiologist and continues making a substantial profit from that but that still could possibly mean that that doctor that interventional cardiologist was indeed totally disabled. Doesn t matter that he changed his practice after he became disabled and you know prior to disability.
10 to 15 percent of his duties were you know general cardiology based on the language of the policy at the time..
He was disabled the substantial material duties of there s occupation were interventional cardiology. Do you know we re interventional cardiology with you know let s say 25 percent office visits or clinical. That were incidental to interventional cardiology. So it s a very complex analysis sometimes that s why the cpt code production and the cat labs.
The cat lab that is important because you re there to prove your case and the cases. The case law is very clear i mean the burdens always on the insured or in this case. The interventional cardiologist to prove his disability to prove whether they re totally disabled versus partially disabled. So we do find those gray areas those are areas that are highly contested.
I ve seen we ve seen case after case after case litigated over that so yeah. I mean that gray area comes up for the interventional radiologists. The same thing about the radiology procedures. And it comes up for the dentist who stops doing the crown and bridge and the extractions and it s just doing you know general oral exams.
It comes up for the general surgeon and we ve tried those case. You know we ve taken that case to verdict before where your general surgeon. But then you re only doing some endoscopy procedures. But you re not cutting the skin anymore so are you total or residual.
So every single one of these cases. The key is it s very fact specific and you have to be prepared to produce the data mostly being the cpt codes or 88 codes or surgical records or hospital or ports. A lot of the hospitals. Yeah and building as well and a lot of hospitals track.
How many surgeries you ve done and things like that so you know that s where we work with you and work with our experts to be able to present this evidence in a manner that will really show what you were doing and so that we can explain to the disability carrier as to why you are total the other thing that sometimes happens is you know they may spend 50 of their time doing something a particular duty. But it s 90 of the revenue right so what do you do in that situation. You know because then they say well you can do what you re doing the other 50 of the time. But you re only going to generate 10 of what you re going to do.
Where does the real line of practically speaking saying okay. Yeah. I can do that one duty. But it pays.
10 of what i was doing so you there s no way i can make a living doing that right and i think that s why court. After court has taken the view that it s a qualitative type of analysis. That s applied okay. It just simply because they continue to work and they continue to perform some of the duties of their occupation.
At the time they became disabled that does not necessarily mean that they re partially or residually disabled. They could be totally disabled okay. So if you are you know if you have one of these policies and you re considering whether or not your total or residual. There s very often people call us and they think they re residual and we look at and go no.
We think you ve been total for years and we were not being evaluated. Properly or you may still be working and not truly understand your options in terms of becoming disabled. And knowing whether or not your total or residual. So give us a call.
We re happy to review your policy review. The status of your claim. Give you a free consultation opinion. As to whether or not we think we can help you and we ll let you know very quickly what ” .
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