Hi, I'm Billy Gwaltney and this is the CYA podcast. This show is for the physician who understands the importance of protecting everything you've worked so hard to achieve. Each week I'll bring you tips and advice to help you cut through the clutter and misinformation and show you exactly what you need to preserve your income and way of life. If you're ready to achieve the peace of mind that only financial security can bring. Let's get started.
(00:28): So welcome to today's episode of the cover, your assets podcast. This is Billy Gwaltney, and I'm as always very happy to be with you today. Today, we have a special guest where we're going to talk about the claims experience with disability policies as a young physician, when you're thinking about purchasing your coverage at the end of the day, the ultimate question is, will it work? Is it going to do what I needed to do?
(00:54): And that's a very common question that we want to do our best to answer today. I have with me, Mr. Dennis Peyton, who is the head of claims for Ameritas life insurance company, as if you've talked to me in the past, or if you've done any research on the top disability specialty on occupation, disability contracts Meredith is at the very top arguably they have the strongest contract. If there can be some debate about that among friends, as far as the top tier, but they're very, very good. Their definitions are very strong. We have a lot of clients with them and we've had clients go through the claims process and, and I've gotten to know Dennis over the last several years and invited him to join us today. And he has agreed to do that so that we can hear straight from an insurance company executive on the claims side, as far as how this works.
(01:47): And so Dennis, welcome to the show. Great. Thank you. Pleasure to be here billing. Yes. Yes. And I'm glad we could, for those of you listening, you might know that the technology required for a couple of people to talk from across the country. Remotely is not always a given. So we've made the technology work and I'm thrilled that hopefully you can hear us clearly. So Dennis there are a handful of questions that, that I want to know answers to and that the people listening to this want to know this the answers to do to this, as I mentioned are, as you know, I work with physicians, young physicians around the country, in all specialties, some are surgical, some are nonsurgical. They're interested in the true own occupation, definition of disability with their policies. So this what's commonly referred to in our industry is the specialty own occupation, definition of disability. And then the enhanced residual, which is partial disability and recovery benefits. And so can you start out by providing a little bit of background for, for what got you to becoming a claim specialist and a head of claims and what that, what that track looks like? Sure.
(03:00): I got out of college. I had worked in a office setting where I was actually working in there. They were self-insured and I think that sparked the interest. I think like most claims people, I think they kind of stumble into it and I believe that once you're there, you either enjoy it or you quickly get out. And so I've been adding up the number of years and I've been in the business and I've always been in claims and on disability short-term long-term and it's now truly over 40 years, I began in the group setting and I won't bore you with all the details, but some of the companies that I've been associated with CNA insurance, Kemper insurance, MetLife, Aetna, and now of course Ameritas. And so I spent a good part of probably 25 years on the group side, which I think was an excellent foundation to really get me ready for the individual side.
(04:02): And obviously they both have their pluses and minuses, but I truly see the benefit of having an individual policy that you can take with you in the event that your occupation changes your employment changes and suddenly where you may have had a really good group coverage to be able to have that security of taking your individual coverage with you, I think has really, at least to me shown to be a great benefit, especially for executives, physicians, dentists, et cetera. So I've been with Ameritas and I absolutely love it. And that's probably where I'll end my career.
(04:42): Awesome. Well, hopefully you're not going to retire for another 30 or 40 years. Right. So the group coverage or being on the group side and a lot of people listening may not even be aware that there is a group side or an individual side or that they would be different. A lot of our clients there that are coming in they're, you know, they're highly intelligent, but obviously been focused on their specialty for the last decade or so. And so when they delve into understanding the insurance world, there's a tendency to kind of perhaps default to treating, okay. If I get a group policy, that's just as good as having an individual policy, you mentioned the idea of being able to, to leave or, or, or carry your private policy or personal policy with you having been on the claims side, on the individual own occupation, policy side, and also on the group long-term disability side. Is there a difference in those how those policies actually function and how claims would be adjudicated over you know, if, if a disability,
(05:49): Yeah. That's a great question. And having had the experience of seeing both sides I can honestly tell you there are, in my opinion, some pretty definite differences between the world of the group and the individual, and I'll just go into a couple of them. And then if you want to meet a dig deeper, please ask in the group, world examiners are really taught more about and they will use the definition of owner. And then some of the, of the group policies have what they call a transition, which means after about the first two years, you go from an own knock into an NDR. And so that's probably one of the, I would say one of the first major differences and what happens is when we're looking at that, Oh, knock, I think there's a tendency for people to say, well, my group has a no-knock and this individual has a no-knock.
(06:46): So they're probably the same. That is not true at all. In a group setting, even though we're looking at it as a quote individual own arc definition, it's really more of what the industry is saying, what is your own arc? So I'll try not to get myself buried here, my example, but knowing that a lot of physicians, you know, they'll say, well, you know, I am an ophthalmologist. So my occupation is very well-defined well, in a group setting, they're going to go out and look at the dictionary of titles, occupation, and use. What does the industry think of when they look at the title of what is an ophthalmologist, for instance. So they're going to say, Oh, that, that, that doctor does eye exams and some surgery and all of that. Well, the difference is when you compare that to a true, Oh, knock in an individual policy, we don't do that.
(07:45): We're not looking at what is the general ophthalmologist type of duties that are performed. We're looking at very specifically, what does our insured do? So good example, I'll keep with the ophthalmologist. We have a lot of doctors and you can take this to whatever field you're in and you can probably appreciate what this means and probably stayed at better than I can, but I think you'll get the idea. Optimologist all doctors sometimes really specialize in what they ended up doing. So I know for example, we have claimants who are ophthalmologists and they have really specialized in that. They really only do cataract surgery, right? They've tailored their business. And again, we can go into any other specialty that you want, and there are multitude of specialties. And that doctor will say, well, you know, I, I can't do my occupation. Well, that's where the D the big difference comes in.
(08:43): So is in a group setting, they're going to say, well, I know you can't perform surgery anymore, but that's just one of the duties that's listed here. So, whereas we're looking at the two policies, we look at it and say, well, their primary duties here is performing the surgery. They are unable to do that. They're going to be considered totally disabled, where in a group setting, I think that net is cast a lot wider. And they may say, well, no, we're not really going to be considering you to be totally disabled. So that definition of group versus individual tool can really, really be a difference when it comes to claim time.
(09:27): That's an excellent example. I talked to clients and ophthalmologists are, this comes up a lot. I mean I have a lot of clients that do that in those specialized, in cataracts or corneas or whatever it is because they, and they go to fellowship specific training for that. And then over the course of their career, they really, that becomes a very narrow lane that they are known for. And so their question is, okay, if I can still do clinic, if I can still see patients and read charts and do exams but I can't do what I love to do. And I'm known for doing, am I disabled? So my, so here's the question off of that, Dennis, is that let's take a group policy that says, okay, according to the national standard for what an ophthalmologist does, if you can't do surgery, that's one part that, but you can still do a lot of these other parts and the keyword being you can do to me, I, here I can do, they can do that. Does that mean that they get nothing? Or does that mean they get a residual benefit or what happens if they go, we're not considering you totally disabled because you can't do surgery, but you can still do these other things.
(10:39): That's a great question. And that had come up a lot in a group setting. So typically what you'll find is they will then steer you into their definition of a residual benefit, because exactly that you said, Billy, they're going to say, well, yes, surgery was part of what you've done, but you also do all these other things. And here's where the individual may say, well, but I didn't do that. And that's, I'm really going to matter because they're, again, they're looking at what is out in the industry. What is the normal type of duties? If I can break away just for a second, maybe make this a very good example. One of the things that I know we do, and I know we're not alone. When I say we, I mean, we in the claims industry, but certainly here at Ameritas, we do the first thing we do when we get a claim is we're going to ask the physician to provide us with their CPT codes.
(11:31): And those CPT codes will tell us what were the primary duties they were doing. So most definitions talk about that in order to be disabled you have to be unable to perform the material and substantial. So for our company, there is no magic number that says, Oh, it has to be 50% or 40% because we're looking at an array of things that can happen. You may only perform surgery 50% of the time, but that 50% of the time accounts for 90% of your income, right? So looking and saying, well, you can still do office visits. Well, if you really kind of peel back that onion, you realize if you have specialized in only doing cataract surgery, then your practice is so limited that your patients are going to dry up very quickly. If you're unable to perform surgery, you know, the idea that while you can still do office visits, that's for what those offices is typically are needed in order to determine if you need surgery. So in the, in a group setting, you may be now deemed residual. Whereas in, on the individual side, we would consider you totally disabled.
(12:51): Yeah, that does. So, so basically it, it, it means that a, a group policy, if they think they have 60% up to 15,000 a month and their income goes beyond that. So they're just a typical physician naturally would say, well, my employer has given me this. I can account for 15,000 a month. If I become disabled, I just need something to supplement that. It sounds like you're saying, be careful about how much you lean on that 15,000, because it can get muddy relatively quick. If the definition is not a catastrophic type of definition, is it is exactly fair. Fair, fair to say.
(13:28): Okay. Okay. So switching to an individual own occupation coverage against, and I, and I, I know you, you speak in specifically in your experience with Ameritas. I don't expect you to speak for the industry at large because you can't cover all that, but in your setting, is there a sense of more when you own a true specialty own occupation, Def definition policy, that there's a benefit of the doubt more so than in a group policy or association policy where they're kind of not giving you the benefit of the doubt. I mean, in other words, is that fair to say that kind of presumption? Yeah.
(14:08): I think that that's a fair statement. I think why would also add to that ability is that like our, our examiners, their caseload, when you look at what they're managing and who they're speaking with and claims that they're handling it is very common that over 80% are probably their workload is dealing with physicians. So, you know, by pure exposure, you get used to what are the duties of these various doctors? And I think it gives them a little bit of a comfort, knowing that when they're speaking with their examiner, that we know the lingo, we can talk about, you know, your CPT codes and the different types of specialties you have when you compare that to a group. And again, this is not to disparage anyone in the group, world that's great coverage, but the idea that their majority of their workload would be handling positions is probably just not true because they're handling all sorts of occupations. So I think there's an added benefit of a company who has a great deal of claims and volume dealing with that. So, you know, I probably don't know more about what different doctors do and their specialties than I ever have in my life, just because of the pure exposure. Right.
(15:25): Okay. So that leads to the next question. You're probably aware that, that some people have a presumption in just out you know, when it comes to insurance, that if an insurance company can avoid paying a claim, they will. I mean, it's like, it's, it's hand to hand combat, you know, if, if they can figure out a way to do it, how would you be in kind of a, an insurance insider at a particular company? How would you answer this question for a young physician? Who's looking at coverage, but is, has a significant and perhaps legitimate fear that it's not going to do what they're paying for it.
(16:03): Yeah. I think that's a legitimate question and a legitimate concern. I think one of the things that I can say, and again, I will speak about Ameritas and how we handle it, but I would also say that it's probably not that much different without the industry. Like you said, Billy, I can't speak for the others, but I certainly know how we handle it. And the first statement I'm going to make is not meant to sound trite. It's just a really, maybe put it in focus or rather quickly, it's much easier to pay a claim that it is to deny it. I mean, if you think about it, we look at our our insurance. These are people who are typically high earners. They've gotten in, they have spent years of education to get where they are. If they are trying to utilize their disability policy, it is probably because they have already tried everything else they can to keep working.
(17:00): And they just can't. So we, we're not seeing people who are just, you know, Oh, I think I'll just pass you in on this. And, you know, collect a little bit. They can earn so much more by working. So the fact that they're submitting a claim right off the bat, our immediate response is this is probably a payable claim. And as odd as that sounds, when you approach the claim at the beginning, that it's probably going to be payable, then all we're really doing is facilitating the physician by gathering what we need to go ahead and pay the claim. So we kind of start out with the assumption that this is probably payable because we do not keep track of, you know, the percentages that we pay versus deny. But I can say with certainty that the number we pay are tremendously greater than the few that we deny, because at the end of the day, if we're going to deny a client, we have to make sure that, you know, we have tried to work in good faith with the physician to get what we need.
(18:05): And at least in our world, there are no surprises. If we're missing something, we're going to tell you if you're saying, well, I don't understand why, you know, you would've thought that if you'd gotten the report from Dr. So-And-So, you would have paid this claim. Well, that's where that communication starts by saying, wait a minute, we don't have any records from Dr. So-And-So. So right from the beginning, when we begin the claim, it's a conversation. And it's also an explanation, meaning that a lot of times physicians bought these years ago. And quite honestly, they probably haven't looked at their policy in years. So we want to educate them, explain what their benefits are. Kind of give them a roadmap. Here's what we're going to do. Here's what we're going to need, and really walk them through the process. And if we're not going to pay a claim, it's not going to be a surprise. We're going to let them know here's what we're seeing and give them a chance to basically say, what are we missing now? Again, I can't say that all insurance companies operate like that, but I know that certainly the way we did.
(19:11): Okay. Well that when I'm talking with clients, I do tend to make sure they understand that, that having a policy with a company that is going to have a posture of, of giving you the benefit of the doubt is a huge asset compared to, you know, if you're employee at a hospital where, or whatever, wherever you're in the group setting where they're typical claims are much different. And we're not dealing with so many physicians like you guys are that benefit of the doubt strikes me as a very important feature to have. And I guess at the time of claim. So, so this leads to another question. I I've had clients become disabled. I've had clients I've gotten messages and talk to them on the phone. And, and what happens at a time, a claim? What is, so what I, one takeaway I've had is that whoever is disabled or recognizing that they're disabled and moving down this road of having to use their policy, that they hoped and basically assumed that they would never have to lose or use, excuse me, their world has been completely up-ended and I've had clients cry on the phone.
(20:23): I've gotten messages where they're, they're like literally balling on the phone because the emotion is so heavy. The, and they're scared to death. I mean, that elimination period, when they're going through the claims process to confirm that it's actually going to do what they expect it to do, they're on pins and needles. They're worried, they're afraid their life is, you know, perhaps never going to be the same again. And so their plan a hasn't worked their plan a, they need this plan B to be what they've hoped that it would be. So when that happens as a company, how you guys approached this, can you walk us through a typical claims process? And is it, are you sensitive to, I don't want to make this emotional or anything, but are you sensitive to the emotional impact that a person's going through when their world is up ended and they're, and they're scared to death and how do you kinda walk them through what they need to do in order to make sure that they can have peace of mind that a check is going to show up when they expect it to?
(21:21): Absolutely. And those are all great questions, right. You know a lot of times when we do get the notice of claims and I'm probably going to hit a broad array of topics here, so keep me in the lane if you need to, but sure, sure. A lot of times we'll get a phone call from the insured or from the agent saying, Hey, they're not even really sure when to file the claim. You know, I have a 90 day alum, but do I wait until the 90 days is over or do I file it right away? And my answer is almost always the same. And that is if you, as a physician, especially, they've kind of got a little added knowledge that a lot of times what I already know where their condition is taking them. So if they're saying, well, look, I I'm only been out 30 days, but you know, I think my recovery is going to be well into several months before.
(22:09): And it's going to be kind of a wait and see our answer's always the same, you know, go ahead and file the claim. Let us go ahead and get that background. Let us get the medical records we need. So that our goal is that by the time the elimination period is over, we're already a letter in your hand letting you know, we've accepted the claim and ready to make that first payment. So one of the things we do when we get a claim is once we get notice, we make a phone call out to the insured. And obviously we ask if, you know, it's a good time for them. We're certainly knowing what their condition is. We know that it's all, as you said, Billy, sometimes a very trying time, depending on the severity of the condition. And quite honestly, as I mentioned before, they probably have not looked at this policy sometime in 10, 15 years.
(23:05): So they kind of try to read through it, but they're not quite sure all that it means. And I think one of the best benefits that we're able to provide is we say, well, what we'd like to do is kind of walk through your policy and let us explain, you know, some of these terms, let us explain what you can expect. We're going to explain what we're going to be requesting of you. And probably more importantly, the why, why do we need this? Because at time of claim, I think sometimes people will, can just be overwhelmed with the amount of information that seems like we're asking for. But a lot of times we do have to understand their financials. We need to understand how many different doctors they're seeing, who is doctor that is telling you, or doctors that is telling you that you're not able to perform your duties.
(23:52): So it's really, and I don't want to over step that one either. That's the time where we're going to do a lot of listening where we're going to say, why, you know, I see a doctor that you are a radiologist, so we don't make the assumption that, Oh, well we know what you do, your radiology, we have them explain, you know, because they're, again, they're specialties and radiologists. So we want to know w w what do you do? That's a typical conversation that we ask is describe what your typical day was before you became disabled. And then we'll go through the rest. We'll explain that we're going to be sending them out forms, what we need, explain how the elimination period works that, you know, yes, you have a 90 day Lam, and then we pay in the rears. So you're not going to get your first check until really that fourth month.
(24:46): And truly our goal is that, and this is why we try to reassure them. Our goal is to get everything we need. And as soon as we know that we're ready to pay this claim, even if it's at day 80, you're eliminated your elimination, isn't even over, but we already have enough that we know we're going to accept this claim. That's what we want to do, because I think that gives them that peace of mind that, okay, good. Because they've got a lot of other things going on in their lives. They've got all these medical issues and things that they weren't dealing with, family issues, et cetera, to where one of the things we want to do is kind of give them that reassurance that your pay is secure. So you're going to get this on a monthly basis. Here's what we're going to do. Here's what you're going to need to in some or report to give them some relief. That that's one less thing they have to worry about.
(25:40): That's really good. That's really helpful. Thanks for that explanation. So unique to Ameritas is something that a lot of our clients that have Ameritas pick Ameritas for, and it's a, it's a perk, I guess, or what I describe as a, per called a non disabling injury benefit that comes on their policy. Can you explain how that claims process works differently than what you just described, where you have 90 days and it's like a total disability claim or, or longer term disability compared to the non-disabled injury?
(26:15): Absolutely. I'm going to give the example that is not only a just an example. It's probably one of the ones that we get the most type of claims on. We'll get a call and a doctor will say I was out on a skiing trip with a family, and I took a tumble and I didn't break my leg, but it was badly sprained. I'm going to miss some work, but I was reading here or, and, or my agent, let me know that, Hey, when, and don't forget, got this non disabling benefit, which I'm not really sure what that means. Could you kind of help me describe what it's as? And it's like, well, you're not missing enough work. So you're, you're, you've already said you're only gonna miss about a week's worth. So you're not gonna meet the 90 day limb. But if you suffer an injury and incur medical expenses, that this provision allows you to submit those expenses.
(27:07): And it's probably one of the fastest turnaround benefits we have, because it's really a no brainer. All we need is the form filled out. We're going to see where you were skiing. You went to the emergency room and you incurred it in this day and age. It's not uncommon to quickly incur $5,000, one quick trip to the ER. And they're saying well, but I don't really think that I should submit this because I had medical coverage and, you know, they've covered everything, but you know, a small deductible. So is it even worth me turning it in? And we're always like, yeah, this is one of the perks of the benefit. Turn it in the non-disabled industry benefit is typically 50% of whatever your monthly income is up to a maximum of 3000. So if you have a 10,000 a month policy and you have $5,000 worth of ER expenses, you submit that to us.
(28:06): And we quickly go through and say, yep, you were covered no problems. And we will send you a check or deposit it right into your bank account, actually a check for $3,000. Well, then the question is what, wait a minute, wait a minute. My medical coverage already paid for all of this, but the deductible, which was 500. So aren't, you kind of overpaying me and it's kind of like, well, no, we're not, this is just a benefit. We can pay up to 3000. So the fact that you got everything paid, but the 500 is just somewhat of a bonus, right? Of course, that can work the opposite too. You know, you can end up being in the hospital and your medical hospital stay is $50,000 and your deductible was 5,000. Well, we're still only going to pay the maximum, which is 3000. But the benefit of that is it's really kind of helping you pay for that deductible. Right? So it's a benefit that people tend to forget because it's not one that they think of as part of their disability policy. And it's often a time when they're ready.
(29:13): The agent is meeting with them on an annual basis, or whenever they're scheduled to meet with them, they'll just simply ask, Hey, how things go? And it'll come up in a topic, you know, you're doing great, except for my spill. So we get a lot of notices that happen after the fact. And that's okay. We know that happens. And those things are pretty easy to submit a lot less paperwork and a very turnaround. I've had two situations. I had one client where she got paid and she, she was the first example you gave. She made a profit, her, her situation. She only had a couple of hundred dollars out of pocket, but she had like a $2,000 MRI. So you guys sent her a check for around 2000 and then she called me and asked like, her, one of her question was really funny because she just said, is this legal? I was like, yes, this is really delicious part of your contract.
(30:10): She was like, is this Medicare for all? Or this isn't some kind of like thing. I was like, no, no, no. It's just part of your policy is a perk for having it. And so that, I felt that was really interesting, her response, like this seems like it shouldn't like it shouldn't be, and yet that's contracts, you know? I mean, if you follow this back to you, you get a benefit, you know? And so, yeah, I'll give you two other examples. If you don't mind that come about quite often, you know, this day and age, most people have some sort of medical coverage. And even while there may have met their deductible, there's this discount that's provided. So the original bill was 5,000, but it got discounted down to 2000 and then all you owed was a 500. So they look and say, they, their expectation is, well you'll at least reimburse me for that 2000, but we look at the actual expense.
(31:05): So if the bill originally was 5,000, it doesn't really matter to us that your medical provider discounted it down to two. We would still, in that instance pay the $3,000. So you're right. There are instances where sometimes people feel like they've actually benefited from this, right? Another one that happens frequent is the person will have their accident. And they'll say, well, I don't think I'm going to miss that much work. So they'll submit the claim as a treatment of non disabling injury. We'll go ahead and pay the 3000 or whatever the max is. And about six, eight weeks later, they'll call us and say, well, you know, I ended up having, you know, some complications and now it looks like I'm actually going to be out more than my 90 days. How does that work? And when that happens, what we do is we end up paying you a total disability. We just subtract whatever it was. We paid from the non disabled. You can't collect both. Right? So if you're going to collect it as a disabling injury, obviously that's usually worth more. But if you, if we end up penning at once and then ended up paying a total, we just take it out of that first benefit. So it's moral to that story is if you're not sure whether or not go ahead and cash it in and get some money up front, and a lot of us do. Hey, there, hope you enjoyed part one of this episode. It's just too good to limit to one show. Join us next week to hear the,
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