Disability insurance, Part II

Some docs wonder if the plan is a sham — and propose a new way

By Gillian Woodford

In this second and final part of our investigation, we look at some more of your concerns, and some potential solutions.

GIVING ATTITUDE
The multifarious attitudes that surround the issue tend to lead to crossed swords. Doctors won't like the sounds of OMA Insurance Services Managing Director Jacques Rocheleau's theory that some doctors use the disability to facilitate a lifestyle choice. "For example," he says "one 50-year-old will have a heart attack and go back to work after three months. Another 50-year-old won't think he can ever go back to work. Sometimes it's a lifestyle choice and the adjudicator has to decide 'is that necessitated by the medical condition?'"

While whether Dr Hossenbux's daily rehabilitation regime constitutes a lifestyle choice isn't up for debate here, he thinks doctors' own attitudes don't help. "Your own colleagues think you should be superdocs — they have scant sympathy," says Dr Hossenbux. Dr Hebb feels that younger colleagues sometimes don't understand the strain that years of often gruelling practice can have on an older physician's health. In addition, many MDs are reluctant to document their ill health for fear of seeming less 'tough' before their peers, and also because it could disqualify them for disability insurance or other health insurance in the future.

UNAPPEALING APPEAL
Another contentious aspect of the Sun Life plan is the appeal process. Dr Hebb was puzzled when his second claim was refused, so he decided to appeal. "You have 60 days to appeal — but you have to try to change the minds of the same people who refused you." Sun Life told me they couldn't explain their appeal process to me because of the OMA plan's confidentiality. When asked about it, Mr Rocheleau was at liberty to elaborate on the process: "There are two ways people appeal: first, providing additional information. In some situations, where additional information is needed, the original case worker handles the appeal. Second, if there's a disagreement, or if the claimant wants a second opinion, it goes to another group of people." He said the appeal would not, however, go to another physician for a second opinion.

Nonetheless, Dr Hebb faxed NRM the correspondence between him and Sun Life, and it does seem that his appeal was initially handled by the very same case worker. It eventually ended up in Sun Life's ombudsman's office; which found nothing remiss in the handling of his case.

CASH BACK
Although every doctor we spoke to acknowledged that insurance companies are absolutely justified in investigating disability claims, they all expressed a niggling suspicion that the OMA and Sun Life were somehow profiteering from their misery and illness. Mr Rocheleau staunchly denies that anybody is making a buck from this plan. "There are approximately 12,500 physicians insured under the OMA Disability Income Plan," he explains. "Last year, annual premiums of just over $22.5 million were collected, and nearly $9.8 million were returned as premium refunds. The plan operates on a not-for-profit basis which means premium refunds are returned to insured members whenever claims and expenses are less than premiums collected." Last year many of you will have received a refund of 49% of the premium you paid.

DOC TO GOV'T: HELP
Although those refunds are undoubtedly welcome, some say they're ultimately not worth the price physicians pay in other ways. Dr Charles Shaver, a general internist from Ottawa, contacted us with his story — and some suggestions for a solution. "I hadn't taken a day off since 1975," he says, "when I had elective surgery on my foot." He was off work for two months and worked part time for one, in a wheelchair and cast. He made a claim to Sun Life after his 60-day elimination period and was initially refused. He fought them and eventually managed to get about $1,000. But he says if he hadn't worked some extra emerg shifts before his operation he might not have been able to make ends meet. "I don't care how much you think doctors make, everyone spends what they make," he says.

But Dr Shaver has an idea — one he says the OMA was too afraid to present to the government during recent contract negotiations. He proposes that as a way to keep older doctors working while the new crop is getting trained up, the Ontario government should provide guaranteed income replacement in the event of disability. (For details of Dr Shaver's plan, check out his guest editorial, "We have a right to expect proper disability coverage," on page 8.) He adds that since Ontario doctors now have no choice but to pay dues to the OMA, they no longer need to push group insurance, traditionally a way the OMA kept their membership up.

Dr Hossenbux says he's not crazy about their sale tactics. "The OMA really pushes the plan — they send out pamphlets two or three times a year. They instil fear in you — 'protect your family, protect your career.'" He has his own ideas about how doctors should cover themselves in case of illness: "Doctors might be better off buying bonds to act as an emergency fund," he suggests.

As for Dr Hebb, he's still working those 12-hour emergency shifts. He hasn't bothered to cancel his disability insurance — "it runs out in January." Until then, he says he'll keep fighting while, as he puts it, Sun Life and the OMA "just keep circling the wagons."

— Additional research by Phil Burns
Need support? Contact the Canadian Association of Physicians with Disabilities: www.capd.ca.