In my experience, physicians and dentists love asking about hypothetical claim situations and whether or not a disability policy will pay a benefit in various  situations. Below is a riddle that deals with a unique hypothetical claim situation and which illustrates the beauty and complexity of “Own Occupation” definition of total disability. Good luck solving it. (Spoiler Alert – the answer to the riddle is given later in this post.)

While the hypothetical doctor in the riddle is an Internist, the following scenario would work for other medical and dental specialties as well.

The Riddle

A hypothetical Internist named Robert Taylor purchases an Own Occupation / Specialty, individual disability insurance policy today and later collects total disability benefits from that same policy even though he:

  • Was never totally disabled as an Internist, and
  • Was never unable to perform the material and substantial duties of an Internist, and
  • Would later receive benefits for total disability even while working full-time as an Internist

How could this happen?

In order to solve the riddle you will need a clear and broad understanding of Own Occupation / Specialty Coverage and be able to apply it to a hypothetical disability claim situation, so I’ll generically define some important terms:

1. Own Occupation Definition of Total Disability:

  • You will be considered totally disabled if, due to injury or sickness, you are unable to perform the material and substantial duties of your occupation.

2. Your Occupation, as used in #1 above:

  • The occupation in which you were engaged at the time you became disabled.  A few carriers define your occupation to be your medical or dental specialty if you have limited your practice to a recognized specialty.

This claim involves Total Disability only and does not involve Residual (Partial) disability in any way. It is not a Presumptive Disability or any other situation that might “automatically” qualify one for Total Disability. Dr. Taylor qualified for Total Disability by meeting the policy’s standard definition of total disability, meaning that, due to injury or sickness, he was unable to perform the material and substantial duties of his specialty.

Have you solved it yet?  The answer to the riddle is next.

Answer to the Riddle

A year after Dr. Taylor purchases the disability policy, he decides to enter a Gastroenterology Fellowship.  Three years later he completes the Fellowship and begins practicing Gastroenterology.  Soon he is specializing in procedures and surgeries and is generally very happy with his decision to change specialties.

However, as you know, there is a total disability in Dr. Taylor’s future and, sure enough, a couple of years into his new GI career, he injures his right hand which is his dominant hand. The injury would not be considered serious to the average person, but it causes some permanent loss of use of the hand and he can no longer perform most of the procedures and surgeries he was doing before.  In other words, as a result of his injury, he is unable to perform the material and substantial duties of his occupation (Gastroenterology).

This easily qualifies Dr. Taylor for total disability according to the terms of his disability insurance policy, and he begins collecting a monthly disability benefit check.  Dr. Taylor is happy he purchased such a good disability policy, one with Own Occupation and which recognizes his medical specialty as his occupation.  As happy as he is though, he realizes that he would rather be working somewhere than sitting at home.

It occurs to Dr. Taylor that because he has an Own Occupation policy, he can take a job in another occupation and still receive his full disability benefit check.  In fact, while he is considered totally disabled as a Gastroenterologist due to his right hand injury, he is perfectly suited to begin practicing as, you guessed it, an Internist.  Dr. Taylor does just that. He calls the Internal Medicine practice where he formerly worked and they are happy to welcome someone so well trained and experienced to join their practice.

In his new job as an Internist, Dr. Taylor earns a regular paycheck, but he also continues to receive his full disability benefit check every month because he is still totally disabled as a Gastroenterologist.

And that’s how a hypothetical Internist named Robert Taylor purchased an Own Occupation / Specialty disability insurance policy and later collected total disability benefits from that same policy even though he:

  • Was never totally disabled as an Internist, and
  • Was never unable to perform the duties of Internal Medicine, and
  • Continued to receive benefits for total disability even while working full-time as an Internist

Is that cool or what?

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