First, let’s start with what their Choice contract states:
Total Disability Definition: Enhanced True Own Occupation - You will be totally disabled if, solely due to injury or sickness, you are unable to perform the material and substantial duties of your occupation.
As long as you are totally disabled, benefits will not be reduced even if you are working in another occupation. You will also be considered totally disabled if you are an MD or DO and more than 50% of your income is from:
Performing surgical procedures and, solely because of injury or illness, you can no longer perform surgical procedures -or- perform hands-on patient care and, solely because of injury or illness, you can no longer perform hands-on patient care.
Second, let's unpack the pros and cons of the clauses:
>>The pro is stating that percentage, this being present in the contract can make someone feel comfortable because it has a clearly defined number.
>>The con is what happens when that surgeon had 49% of their income from surgery and the rest was from clinic work which was being referred to them, or possibly by consulting or even have work in a surgical center? Once they personally can't do surgery, are they still going to get the referrals for the clinic work that was making up 51% of their revenue; how about the consulting aspect - will the surgical centers suffer? Other carriers might certify that as a total claim but Guardian might only certify that as partial since the 50% number was not hit.
My message to you is that you never really know exactly how a carrier might handle a claim because we don't know exactly how a practice/physician is performing or running their practice at the point of claim. Since I am not an attorney, my opinions are based upon working with these disability contracts for almost 30 years and our team working closely with the insurance carriers. I feel it is important to let our readers think about this in more detail as this is a common question that we face on a daily basis; as this situation depends on each individual's specialty and employment model.
I currently don't put much weight behind the '50%' rule because where it can make one feel comfortable, it actually could work against the insured. If at claim time the codes came back that 49% of the income was derived from surgery, now the carrier has firm footing to stand on saying that they don't have to pay a full claim because it was not 50% or higher. When this number is not present in the contract, I have seen carriers pay full claim on someone that is generating as little as 38% of their revenue from surgery. It is easy to tell that the other billable CPT codes would not be there without the surgeons’ capacity to do the surgery because the referrals would not be there.
At the end of the day we understand that it is a comforting factor for one to look at that number as a hard line drawn in the 'sand', just be sure you are not standing on the wrong side of that line.
So, the bottom line here is that we want to help you find the right contract for your specialty and future practice needs. When we are asked whether or not Guardian is the superior contract, we cannot offer a substantiated, quantitively firm 'yes' because that data to support this theory does not exist.
In order to find the superior contract that is best for you, all variables and discounts available will be reviewed on a case by case basis. Since Guardian has 3 versions of their contract, we unpack the differences for you during our clients consultations so you can select and design the best plan for you based upon your current situation while also comparing their contracts to the other five own occupation carriers out there in the industry.
This way you can feel confident that you have made an educated decision before an application is taken - a decision that is specific to you and your needs.
If we can help, give us a call at 713-966-3932 or schedule with us HERE.