Do Physicians have restrictive provisions when it comes to mental health related disability claims?

Many physicians we meet are worried about potential limits or restrictive contract language when it comes to their Own Occupation disability coverage. If they experience a disabling event from depression, anxiety, stress and/or substance abuse, will they have any coverage? Their concerns stem from clinical burnout being a concern for trainees, but the reality is burnout in and of itself is not a covered disability.


JAMA reports: Physicians across multiple specialties report high levels of burnout and occupational stress. Trainee physicians experience similar, if not higher, levels of burnout compared with practicing physicians. This higher level is likely not just a generational phenomenon, as burnout among trainee physicians is also higher than among their age-adjusted, non-physician peers. Understanding burnout is important because it impairs clinicians’ effectiveness at work and is detrimental to their mental and physical health.


So, how does this factor into a disability insurance claim under an Own Occupation contract offered by one the Big Six? It depends on your specific base contract and Mental/Nervous Rider you have purchased. Additionally it depends on whether or not you had a pre-existing condition that caused an exclusion at the time of your original insurance offer.


We get told that Mental/Nervous claims can be as high as 9%, but that number is coming from Social Security Disability Income (SSDI) claims; which include all people across the entire US population. Residents, fellows and attendings have so much sweat equity in their profession so although there is burnout being reported, physicians deal with issues that the general population doesn't on a daily basis. In short, physicians may have a higher stress tolerance than the average person in the US on SSDI.


What is a Mental/Nervous rider - generally speaking?

If the condition falls within medical codes for Mental, Behavioral and Neurodevelopmental disorders, it is considered a Mental Disorder and will be subject to the policy limitations.


So if you don't have a current history of being treated for anxiety, depression, stress and/or substance abuse, it is possible that you can apply for a 12-month, 24-month or an unlimited window of coverage on a new application. Buying the unlimited version should be because you find it necessary and want to pay the increased premium for that feature.


If you have any current or previous medical history (which may cover a timeline of 2-5 years) including therapies and/or medications in this category of care, you will probably have an exclusion for those conditions. Conditions that fall under the category of mental/nervous which then typically excludes anxiety, depression, stress and/or substance abuse even if you are treated for just one of those.


Reminder: If you have a medical exclusion, you will not get coverage if you are disabled from depression, anxiety, stress and/or substance abuse. This exclusion will be disclosed to you at the time of offer and you will have to sign an amendment noting that you are aware of such an exclusion during your contract look over period. However, your contract may allow for you to have some additional coverage outside of the four named conditions. See below!


Is there more cognitive coverage available on an Own Occupation plan, even with an exclusion and/or in addition to the benefit period you have chosen?


Possibly. Most Own Occupation contracts have options for insureds to collect on claims for organically caused disabilities above and period the term chosen.


This category of conditions are caused by a number of diseases and disorders; to include but not limited to: stroke, head injury, viral infection(s), Alzheimer's or similar organic diseases. Due to the state and specialty variations, we are happy to discuss this with you on a case-by-case basis as there are many variables to discuss; especially if you have an older contract.


As of 2021, these are the options you can choose from by carrier; with an understanding that contacts can be different based upon state of issuance, medical underwriting and medical specialty:

>Ameritas - could allow for a 5-year benefit period; sometimes the 24-month benefit period applies*

>Guardian - allows for the choice between a 2-year or the unlimited benefit period*

>MassMutual - allows for the choice between a 2-year or the unlimited benefit period*

>OhioNational - allows for the choice between a 2-year or the unlimited benefit period*

>The Standard - allows for the choice between a 2-year or the unlimited benefit period*

>Principal - allows for the choice between a 2-year or the unlimited benefit period*


Knowing that you can have coverage for anxiety, depression, stress and/or substance abuse for a maximum 2-year window (unless hospitalized) and possibly have additional coverage for organically caused disabilities, many opt for skipping the full mental/nervous rider as they would rather save in premium costs.


*Again, you will need to inquire specifically with an insurance broker to know exactly what is available to you as each carrier could have a variation based upon the state your contract was/will be issued in.

For those clients that have a family history of mental illness and worry about burnout for themselves personally, could then consider opting for the full benefit for peace of mind. If you want to learn more for any of the reasons listed above, we are happy to take a call 713-916-3932 or you may schedule a time here. Happy #MentalHealthMonth to all!


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