Insurance. It's one of those
necessary evils we love to hate. But there are rumblings
among physicians who participate in the Ontario Medical
Association's (OMA) disability insurance scheme that seem
to amount to more than your usual sour grapes.
UNLIKELY
MUTINEER
Dr Farook Hossenbux, a soft spoken and erudite internist
from Ottawa, doesn't seem like a man accustomed to igniting
insurrections. But a letter he sent to this paper in
January has roused a mutinous corner in the hearts of
several physicians subscribing to the OMA's group disability
plan.
About three years ago, Dr Hossenbux
made a claim to Sun Life (the insurance company the
OMA is signed up with) based on diminished hearing that
was affecting his practice. He'd already taken the step
of seeing a specialist himself. "He found a significant
hearing defect and he asked me, 'How can you hear your
patients?'" recalls Dr Hossenbux. The insurance company
sent a team to his office to interview him; they recommended
he see one of their own physicians, which he did. "That
physician wrote a letter supporting their contention
that the hearing problem was not of significance to
impair my practice." His claim was refused.
Dr Hossenbux put in a separate
claim for a bad back, which was also refused. "I initiated
physio myself and undergo rehabilitation in the form
of swimming every morning," says the doctor. Because
of this regime, which he says is essential to ease his
back pain, Dr Hossenbux is unable to work full time.
But he has yet to see a penny from Sun Life.
INSURANCE
FLIP FLOP
One of the physicians Dr Hossenbux's letter struck a
chord with is Dr Mike Hebb, an emergency physician from
Halifax. Dr Hebb has been fighting his own personal
war with Sun Life (medical associations in the Atlantic
provinces can take part in the OMA's group insurance)
since his own claim was turned down. Dr Hebb's story
has a twist, however. He had an identical claim accepted
a year earlier.
"I was suffering from fatigue and
chronic pain," explains the 64-year-old doctor. His
doctor recommended he scale back his three consecutive
12-hour ED shifts to two. "Sun Life sent the claim to
their medical examiner — a seasoned internist I
assume — and he said 'I don't know how he does
one let alone three!'" Shortly thereafter, Dr Hebb began
receiving partial disability payments from Sun Life.
About a year later, he started
feeling better. He decided to go back to three shifts
a week and duly informed Sun Life. "But after Christmas
I started feeling bad again." He made another claim
— same grounds, same recommendation from his physician.
This time it was refused. "It was a different case worker,
and she sent it to an emergency doctor — one much
younger than me (most of the doctors I work with are
30 years younger than me). They said 'Because you don't
have a specific diagnosis we can't say specifically
what's causing the disease.'" To add insult to injury,
they recommended he try working every other day instead
of three consecutive shifts. "I've been doing this since
I was 40," says Dr Hebb indignantly. "I've tried every
combination of shifts and I know what works."
When Dr Hebb asked them why the
same claim had been accepted before, they told him it
was because he was being investigated. It was the first
he'd heard of it.
Dr Hebb understands that disability
claims need to be investigated — "There are a lot
of bogus claims — I see them in emerg every night!"
he says. But he feels he's being penalized for being
honest and for trying to work fulltime again.
CAPITATION
CLAUSE
Not all claims are turned down on the basis of a medical
exam. Some refusals are financially motivated. After
paying into the Sun Life policy for the better part
of 30 years, Kitchener GP Ken Shonk was unpleasantly
surprised when his first and only disability claim was
refused. "I managed to slip on some black ice in the
office parking lot," he explains, "and ended up with
a fractured tib-fib. I was off work for seven weeks.
After two weeks I hired a locum to cover me, but I never
saw a nickel from the insurance company." He pursued
the matter and was told by the insurance company that
the billing arrangement at his group practice meant
he wasn't eligible. "I work in an HSO [health service
organization] and have rostered patients, like a lot
of doctors now," he explains.
Since capitation payments for rostered
patients can continue while a doctor is temporarily
disabled the insurance company did not consider that
any loss of income had taken place. Dr Shonk was astonished
to find that the $4,000 he'd paid for locum coverage
didn't constitute a loss of income. "I showed my accountant
the policy," Dr Shonk says, "and he said the fact that
I'd been paying into it for 30 years and couldn't make
a claim amounted to fraud."
Dr Shonk cancelled his insurance
and has been busy warning his colleagues to read the
fine print in their policy lest they end up in the same
boat. "This policy is going to be useless for people
in FHNs [family health networks]," he says, adding "What
I'd love to know is how many doctors have been able
to collect."
THE
OMA SPEAKS
Dr Shonk and other physicians may be surprised to learn
the answer to that question. According to OMA Insurance
Services Managing Director Jacques Rocheleau a whopping
94% of the 209 claims received from September 2003 to
August 2004 were accepted. He adds, "Disability benefits
totalling $15.4 million were paid to the 366 members
who were on active claim. Of these, approximately 48%
were receiving partial disability benefits."
Mr Rocheleau admits that they have
received complaints from some of the 6% who've been
turned down. But he thinks these have more to do with
the physicians' attitudes than with Sun Life. He thinks
doctors have a hard time accepting when their attending
physicians' recommendations aren't taken at face value.
"Physicians are patient advocates," he says. "But the
attending physician is often clouded by the doctor/patient
relationship. Some of them find it difficult not to
tell them what they want to hear and some will say 'How
long do you want off?'"
But Dr Hossenbux sees the same
potential bias in the insurance company's own doctors
— motivated not by fealty but money. "The insurance
companies pay a hefty fee, around $3,000 I've heard,"
he says. But for him, the main thrust is the OMA's complacency:
"They're touting a poor product, surely they know it's
not the best."
I asked if Mr Rocheleau thinks
the OMA should reconsider its deal with Sun Life. "Based
on these letters? No."
Sun Life was contacted for comment,
but spokesperson Susan Jantzi said they could not because
details of the OMA policy are "confidential." —
Additional research by Phil Burns
Look for Part II of this story
in our next issue
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