Building the Perfect Claim: You Deserve Nothing Less!

February 24th, 2012

Written by Dr. Ian Wexler


Over the past fifteen years, I have handled dozens of successful claims on behalf of my clients. Currently, my firm Protect Insurance has over twenty clients on claim or in the process of submitting claims…a staggering number.  Throughout my career as an insurance advisor, I have always considered, getting my clients paid at claim time to be one of my most important priorities.


Well known insurance industry realities

  • Most insurance advisors sell only a few disability plans a year
  • Most insurance advisors have never managed a disability claim
  • Of those advisors who have a claim situation, the overwhelming majority simply provide the claim forms.
  • Of those who provide the claim forms, less than a handful of advisors in Ontario actually assist with the management of the claim.

Based upon these realities, I have always believed that “who you choose as your insurance advisor can likely be more important than your actual disability contract in determining the actual outcome of your claim!”


Promising you the world

Every dentist has heard a sales pitch from an insurance advisor trying to secure their business. Some incredible ones that I have heard are:

  • “Become my client and I will fight for you at claim time!” One even refers to themselves as a “leg biter” at claim time. The reality in having managed dozens of claims is that this approach is essentially the opposite of what should be done! Insurance claim administrators prefer to communicate with an advisor who will facilitate, clarify and ensure the claim is complete…not someone who is confrontational.
  • “I guarantee to go to the hospital immediately to help you with the claim.” In reality, this comment and action makes little sense. It takes time to compile, review and submit all the necessary financial and medical documentation. Rushing any claim, which unfortunately happens too frequently, will doom a claim to unnecessary delays or failure.


If you think you can manage the claim on your own, think again!

As with every patient and every oral cavity, no two claims are the same. Each claim needs to be assessed, designed and managed differently. Contrary to popular belief, the claim process is almost never black and white but instead fifty shades of grey. Many dentists who hear horror stories of claim denial are unaware of this important fact.


Couple this with the fact that many who become sick or injured, may not be thinking clearly or rationally when submitting a claim on their own. For many, there is an inherent sense of entitlement since, “I have been paying premiums all of these years, the insurance company better pay me!”


The tendency is to rush to complete and submit the ambiguous and complicated claim forms, only to have them returned due to a lack of or incomplete information. In all my years, I have never seen one claim form properly completed and submitted by the claimant. In addition, the majority of physician’s claim reports that I have reviewed have also been incomplete!


Finally, proper claim design, submission and management can be incredibly complicated. Often, important claim decisions which can ultimately determine payment or non-payment of benefits need to be made “with the assistance of your advisor”. This includes partial versus residual disability and defining your actual limitations as a dentist that coincides with all medical reports and tests.


Services every insurance advisor SHOULD provide

When an insurance advisor sells you a disability plan whether long term disability, business overhead expense, critical illness or any other type, it should be the beginning of their service cycle and relationship with you. Instead, it is often the end. If you truly want the highest chance of getting paid benefits at claim time, it is imperative that you have an advisor who has handled many successful claims for dentists, understands implicitly what you do as a dentist and even has a dedicated claim administrator at the company(s) they represent. Additionally, ensure that they offer the following:


  • One on one claim form review/analysis, assistance and completion
  • A complete analysis of how your plans pay benefits at claim time
  • Attending physician’s report analysis
  • Assists with claim design and management
  • Insurance company intervention and communication, as required
  • Consultation and assistance with compiling and submitting financial data
  • Consultation pertaining to medical data collection and documentation
  • Assistance with claim timelines and follow up


Additional services that can be crucial at claim time

There are a number of additional issues that neither you, your spouse nor your practice staff may be qualified or prepared to deal with during a claim. Examples of ones that my firm routinely provide include consultations on:


  • The financial impact of the claim on family, the practice and your retirement planning
  • Future career planning issues
  • Keys to helping you and your family “deal with a disability”
  • Maintaining practice goodwill
  • Partnership/shareholder issues
  • Staff communications
  • Associate and locum placement assistance
  • Patient communications
  • Appraisal arrangement
  • Sale arrangement
  • Transitions consultation


Don’t wait until you have a claim!

It would be prudent for you to speak with your insurance advisor, and to even get in writing, exactly what services they will provide for you at claim time. Ask them how many successful claims they have managed, specifically for dentist clients. If you have an association plan, call the provider and inquire into exactly what their process is at claim time. What you hear may surprise you!

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