Editor's Note: This is part 2 of a two part guest post aimed at helping you to compare the various disability insurance companies and their policies. If you haven't yet read it, start with part 1.
Lawrence B. Keller CFP®, CLU®, ChFC®, RHU®, LUTCF sells insurance for a living, specializing in advising physicians about insurance and investing. Many of you will recognize his name from his helpful comments sprinkled about the site, particularly on insurance related topics. Disclosure: I did not pay Larry to write this post, nor has he paid for it to be published here. If you'd like to say thanks, send some business his way. Now, part 2 of Comparing Disability Insurance Policies.
Cost Of Living Adjustment (COLA) Rider
The COLA rider typically adjusts benefits by a fixed percentage or is tied to the Consumer Price Index for Urban Workers (CPI-U) . Berkshire (Guardian) allows an insured to keep the increased benefit due to the COLA Rider upon recovery while continuing to pay their “old” (pre-disability) premium. The other carriers allow an insured to purchase the benefit increase provided by the rider during disability upon recovery.
Berkshire offers two fixed 3% compound COLA Riders. One that begins after collecting benefits for 12 months (which is standard in the industry) and one that begins after collecting benefits for four years (which provides a 25% savings compared to the first COLA Rider mentioned), and an up-to-6% compound COLA Rider. Union Central offers a 3% simple interest COLA or an up-to-6% compound COLA Rider, MetLife offers a 3% simple interest COLA or a 0-10% compound COLA Rider (the highest in the industry), Standard and Principal offer an up-to-3% or an up-to-6% compound COLA Rider, MassMutual offers a 3% compound COLA Rider.
Future Purchase Option Riders
Generally, the Future Purchase Option Rider amount is a function of the starting benefit level (typically 2-4x the base policy). Some companies will always issue new policies (Union Central, First Ameritas) when the increase option is exercised, others simply amend the original policy’s schedule pages to reflect the increased benefit amount (MetLife, Principal, MassMutual), while for others, it depends upon the original policy series that was purchased and what is available at the time of the increase (Standard, Berkshire). It is also important to know when the increase option will be available to you and in what amounts you can increase your coverage. Generally, you are also paying a premium for the right to purchase a pre-determined amount of coverage in the future regardless of your health. This is not the case with Principal where the Benefit Update (BU) Rider is included in the policy, at no cost, as long as you purchase a total of 75% of the amount of benefit in which you qualify for (in total). However, there is a strict set of rules that must be followed in order to maintain the Benefit Update (BU) Rider on the policy.
Lifetime Benefits
Berkshire Life (Guardian) and MetLife make lifetime benefits available. This means that if you are disabled, on or before the age of 45, benefits for total disability would be paid for the rest of your life. While one can argue that paying a finite premium for a potentially infinite benefit is the best type of coverage tat you can own, there are arguments that can be made against the purchase of lifetime benefits. For physicians, if you own all of your coverage with Berkshire (Guardian), all of your coverage with MetLife, or a combination of the two, you cannot purchase more than $10,000 month of coverage that includes lifetime benefits. MetLife increased the premium rates for coverage with lifetime benefits substantially and, at the time of this writing, Berkshire has done the same in the majority of states. The other states will follow. However, before the 2011 ProVider Plus policy series can be sold in a particular state, that state’s insurance department must approve both the language and premium rates.
Mental and Nervous Conditions
While some carriers cover claims for mental and nervous conditions the same as any other accident or illness, the majority of companies limit these claims to a maximum of 24 months over your lifetime (with the exception of MassMutual, which limits these types of claims to a maximum of 24 months per period of disability and not an aggregate lifetime limit). However, this is only the case if the primary cause of disability was solely a psychiatric or substance abuse disorder or diagnosis, including, but not limited to post traumatic stress syndrome, anxiety, depression and or alcohol abuse/addiction. Companies that do not impose a limitation on these types of claims are MetLife, Berkshire/Guardian (with the exception of policies issued to Anesthesiologists, Emergency Medicine Physicians, Pain Management Physicians and CRNAs, and all policies issued in the states of California and Florida), and those issued in Standard’s Protector Platinum policy series. Keep in mind that policies issued in Standard’s Protector+ policy series do still have a limitation for these types of claims.
Foreign Residence and Travel
While some carriers allow an insured to reside in countries outside the United States of America, the District of Columbia, or Canada, while collecting benefits, the majority will limit payments for these claims. Therefore, if you might consider working outside of the United States in the future or would choose to leave the United States in the event you were disabled. For this reason, you should make sure to purchase your policy from MetLife, MassMutual or Standard Insurance Company – provided their Protector+ policy series is still available in your state. At the time of this writing, those states are CA, FL, MA, VA and VT. Standard’s new Protector Platinum policy series does contain a limitation for these types of claims.
Premium Discounts
Most of the above companies make “multi-life” discounts available through your employer or professional associations in which you are a member. These discounts typically range from 10-20%. However, if unisex (gender neutral) rates are available in addition to these discounts, female physicians can save 40-60% off of the normal female rate structure. Again, an insurance agent or financial planner that specializes in working with medical professionals should be familiar with discounts that may be available.
Summary
While this is by no means an exhaustive list of the differences of the policy provisions between companies and certain policy provisions vary or may not be available in specific states, it certainly serves as a very good starting point. There are many factors to consider when purchasing a policy including your gender, medical specialty, age, occupational classification and geographic location. Also remember that disability insurance coverage cannot be purchased directly from an insurance carrier so it will not cost you anything to employ the services of an independent insurance agent that specializes in disability insurance planning for physicians. (Editor's note: It should be obvious for those who read the entirety of these two posts that there is a real benefit to using a good agent to select a policy. There is no single policy or company that is necessarily best for all doctors. Disability insurance policies are important, but complex and constantly changing.)
Could you comment on role of pre-existing conditions and disability insurance?
For example, I recently had a micro-discectomy done for a herniated disk in my back, and unfortunately have not bought a own occupation disability insurance policy (I am in fellowship). From a medical standpoint, my prognosis is excellent. However, I am not sure how this will effect my ability to obtain a policy? Will there be a rider excluding coverage for back related issues? Can these riders be removed in the future?
Thanks
This one might be a better one for the insurance agents to address, but you’d better believe this is going to be an issue. My guess is you’ll still get a policy for a decent price, but that there will be an exclusion for back-related issues. My policy doesn’t cover injuries that occur while rock climbing, for instance. And forget getting them removed. I tried that once. I mean think about it. If you heal up and get better, then you don’t need it removed. If you don’t, why would they remove it? No other company is going to give you a policy that covers that, so there’s no incentive for the company you have a policy with to remove it. Just like with rock climbing. If I stop rock climbing, that rider doesn’t matter anyway.
You have two options. 1) Lie and hope they don’t find out within the contestability period (this is often 2 years, but you better be sure you buy a policy that actually limits the contestability of pre-existing conditions) or 2) be honest, try to limit the exclusion as much as possible (perhaps only to the L3-L4 disc or arguing that the condition is essentially resolved so you don’t get the rider) and just hope for the best.
Yes, there will be an exclusion rider for your back (or areas of it). However, if the surgery went well and you remain asymptomatic for several years, you will be able to apply to have it removed in the future. The pricing of your policy would not change at all.
Never lie on your disability insurance application as there is a fraud clause that will allow the insurance companies to deny your claim if they can prove that you went out of your way to mislead them and, as a physician, you will be held to a higher standard.
That being said, MetLife is launching a guaranteed issue program for graduating Residents and Fellows (within 180 days of entering practice) that would allow you to purchase coverage regardless of any pre-existing conditions. Your training hospital might also make a conversion plan available to you.
I would be happy to discuss the specifics of your situation with you in detail. If you are interested, feel free to call or send me an email.
Thank you for this series — it’s been invaluable as I finish med school and start trying to reacclimate to the idea of having a paycheck. Do you have any thoughts on when residents should purchase disability insurance? It sounds standard at my home institution and program (in internal medicine) to wait until the final year of residency. Would you recommend purchasing disability earlier, even in intern year? Thanks so much.
You should purchase your disability insurance coverage as soon as possible. This will not only provide you with the protection that you need but allow you to lock into the lowest rates based on your age.
Does it make sense to have disability insurance from 2 different companies (as long as they don’t offset each other).
I have a metlife DI since last 4 years with no provision to increase the coverage. I was planning to buy more. The choises I have now is to get a new policy from Principal for the whole amount or retain my metlife and get additional coverage from Principal financial. Which of the two alternatives would make better sense?
(p.s: with similar terms i.e 90 day elimination, guaranteed non cancellable, own occupation rider, the Principal policy is a little cheaper due to discounts with better terms in the sense that coverage is upto 67 as opposed to 65 for Metlife).
Sunny-
I am a big fan of combining at least two companies (for high income specialties) to allow you to reach a larger monthly benefit than any one company would allow.
Keep in mind that MetLife currently has the highest participation limits in the industry ($30,000 month of individual coverage, $35,000 month with group LTD coverage). Their policy also covers mental and nervous disabilities in the same fashion as any other accident or illness and allows you to collect benefits without limits outside of the United States.
Although I don’t know the specifics of your situation or your existing policy (riders purchase or exclusion riders, if any), generally, I would suggest the purchase of a supplemental policy instead of a replacement of the MetLife contract.
If you want to chat or have me review your options, feel free to contact me directly.
Mr. Keller,
I am a pharmacy student that will graduate in May. I have a term life insurance policy with NML, but was wondering what company you think would be best for me to get a disability insurance policy with?? I was looking at Guardian/Berksire? What are your thoughts?
Thanks so much!
Mallory
Berkshire has a very comprehensive policy and will allow you to purchase up to $1,500 month as a final year pharmacy student. However, they do not offer unisex rates for females (but a 10% discount may be available and some of the other companies offer higher limits.
I would also look at Principal ($1,500 month), MetLife ($2,500 month), Ameritas ($2,000 month) and Standard Insurance Company – if you are not in New York State – ($2,500 month).
Feel free to email me if you desire more personalized information.
You mentioned with Berkshire Life/Guardian you get lifetime benefits if disabled before the age of 45. What do you get if you are disabled after 45? Also what do you know about the AMA disability insurance? They are quite a bit cheaper than my Berkshire/Guardian policy.
The lifetime indemnity amount is determined at the end of your benefit period by your age when the continuous total disability began.
For disabilities that began prior to age 46, the lifetime indemnity is equal to 100% of your policy’s monthly benefit. For continuous total disabilities that began after age 46, the lifetime indemnity amount is reduced (or graded) by 5% for each year.
For example, if you disability began at age 46 (you went one year past age 45), you would receive 100% of your policy’s monthly benefit to age 65 and then 95% (100%-5%) for the rest of your life.
If your disability began at age 50 (you went five years past age 45), you would receive 100% of your policy’s monthly benefit to age 65 and then 75% (100%-25%) for the rest of your life.
Keep in mind that only two companies currently offer lifetime benefits (Berkshire and MetLife), the cost is extremely expensive (it can be more than 50% of the cost of the entire policy) and the maximum monthly benefit available with lifetime benefits for physicians and dentists is $10,000 (in total from Berkshire, MetLife or a combination of the two).
As for the AMA plan, it will ultimately be more expensive compared to an individual policy and provides benefits that are much less comprehensive.
If you go to updates in the disability insurance marketplace part 3 posting, the AMA plan is discussed briefly in the comments section and why it is DOA.
I also have an upcoming guest post that points out the typical problems found in association disability plans and why, generally, they should be avoided.
Rather than buying lifetime benefits, I’d rather get a bigger policy that will allow you to save for retirement in addition to paying your regular expenses so you no longer need the disability payments after age 65. At this point, I have enough saved for retirement that I don’t need disability benefits beyond age 65 (my current nest egg growing for the next 25+ years would provide a comfortable retirement starting at age 65), so I’m glad I’m not paying for them.
Hi Lawrence and White Coat Investor,
Thanks so much for all of the information! I am getting ready to purchase DI and had a question, specifically about the difference in Own Occupation language between Guardian and MetLife. I am a first-year resident and will be going into Ophthalmology. The Guardian policy’s definition of Own Occupation includes medical language, stating that “if you have limited your occupation to the practice of a single medical/dental specialty, we will deem that to be your occupation.” The MetLife Omni Advantage policy has no such language. What does this mean for me, practically, as a future surgeon?
Let’s say I do a retina fellowship and lose a finger, such that I can no longer perform retinal surgery. However, I can still work in the office seeing patients, doing exams, doing injections, etc. (essentially functioning as a medical retina specialist instead of a surgical retina specialist). Will the Guardian policy consider me totally disabled since I can’t do my particular specialty anymore (retinal surgery) whereas MetLife would only consider me partially disabled (I’m still practicing ophthalmology but have suffered a 20% loss of income)? Or would I simply be partially disabled under both policies since I just can’t perform “one of the duties of my specialty” ?
Likewise, if I get an eye injury which prevents me from practicing ophthalmology at all, but I could go back and do an internal medicine residency, would the MetLife policy not consider me totally disabled? That seems absurd.
Obviously the Guardian policy is more expensive, but I”m just trying to figure out the real-world difference between having that language in the policy as a future invasive physician. What’s the real advantage?
Thanks!!
Jeff-
What state are you in? MetLife’s Income Guard is more comprehensive and has been approved in the majority of states and the Omni Advantage is no longer availabe.
In fact, while available, for those in the 4M occupational class, the Omni Advantage policy may be a better choice – but not for Ophthalmologists.
For physicians and dentists, the definition of total disability in an Omni Advantage policy with a “Your Occupation Rider” and the
definition of total disability in a MetLife Income Guard policy with the “Specialty Your Occupation” language have the same meaning.
Both define total disability by looking at the material and substantial duties of the policyholder’s occupation at the onset of a disability.
Neither definition is fixed to a title nor to the occupation at the time the policy was issued. The key element of the definition of total
disability is the regular occupation (and the material and substantial duties) being performed at the time the policyholder becomes
disabled. The Specialty Your Occupation language was incorporated into the MetLife Income Guard product to recognize the different
specialties in the fields of medicine and dentistry.
So, regardless of whether you purchase Guardian, MetLife’s Omni Advantage with “Your Occupation” or the Income Guard, claims would be handled in the same fashion as far as total disability.
For a total disability claim, it will ultimately come down to what percentage of your time are you performing retinal or ophthalmic surgery and/or providing surgery related advice and what percentage of your income comes as a result of performing ophthalmic surgery.
If you are the “retina guy” in a group of Ophthalmologists, it is probably not an issue. However, if you are perforning surgery and seeing patients clinically, both as a general ophthalmologist and as a retina specialist, it might simply be a Residual Disability claim. All claims are different and will be based on the way you practice, what you can (or can’t do) and potentially on how your income is impacted.
Hope this helps. If you want to discuss things in more detail, feel free to call.
Thanks so much for the response. I’m in Virginia and have received quotes from several different brokers, none of which included the MetLife Income Guard. Is that simply because that’s not available in Virginia?
It sounds like there isn’t an advantage at all to the Guardian policy, at least in terms of definition of own occupation. I wonder why their policy is significantly more expensive (although they do have a better residual disability rider)?
Correct. Virginia is one of the few states that has not yet approved the MetLife Income Guard.
MetLife has been very aggressive with their pricing and occupational class upgrades for certian medical specialties. If you couple that with a 10% discount (which you should see on the illustrations), they are among the lowest cost carriers. In fact, for certain specialties, they are even less expensive than Principal for male physicians.
Depending upon the hospital in which you are affiliated, there may also be a 10% discount available on the Guardian policy.
If you want me to review what you have been shown, feel free to email or fax the illustrations to me.
Hi Lawrence,
I’d love to send you what i’ve been given. What’s your email address and I can send that over? Also, another question I had… if the definitions of True Own Occupation do not differ between the policies of MetLife and Guardian, why would MetLife need to update their policy to include specialty specific language? I just feel like I am missing something…
Jeff-
You can click on my name or email me at [email protected].
MetLife introduced their “Specialty Your Occupation” for competitive reasons as it would not cost them anything additional in terms of total disabilit claims as they are handled the same way as “Your Occupation” anyway.
It also positions them more favorably against agents that were trying to sell other companies policies claimng that MetLife did not have a medical specialty definition while other carriers like Berkshire, Standard and Ameritas had it included in their contracts.
I was curious if either you or Lawrence had any opinions on the insurance options available through the AAD. My wife is nearing completion of her dermatology residency and we are looking into insurance options. The AAD offers both life (though likely not enough) and disability insurance (up to $10k/month).
Are these viable options? Or are the better options available through the standard financial institutions.
Thank you,
Travis
Travis-
You should not consider the AAD life or disability insurance policies in favor of individual policies.
As a female physician, your wife should look for an indiviudal disability policy that includes an “Own-Occupation” definition of total disability with a unisex rate strucutre. This will provide her with a savings of 40-60% off of the normal female rate structure.
In most cases, agents that specialize in the medical marketplace, will have access to existing discount plans via her teaching hospital or a professional association.
In the meantime, I added a review of the AAD plan for you https://www.whitecoatinvestor.com/association-disability-plans-all-that-glitters-is-not-gold/#comment-266614 in the comments section of one of my guest posts “Association Disability Plans: All That Glitters Is Not Gold”.
If you would like to discuss your situation, feel free to contact me directly.
Question on help with disability insurance. I currently have a Guardian policy that is good but quite expensive compared to other companies. I am looking at Guardian vs Mass Mutual with the same riders but Guardian is around 1,800 more a year level. Can you modify a policy once it’s in place? For example, could I drop the Graded Lifetime Indemnity rider on the Guardian policy making it cheaper? Any help would be much appreciated.
That’s a great question for an independent disability insurance agent. My understanding is that you can drop riders. Make sure you understand the differences between the policies before deciding on the cheaper one (and have the new one in place before dropping the older one.) It wouldn’t surprise me to see you get a policy that’s nearly as good as the Guardian one for a much cheaper price, depending on your gender, state, specialty, and any discounts available.
Grant-
Yes, a policy can be modified once it is inforce. What can and cannot be done really depends upon the policy series.
If you would like me to review your existing policy and compare it to other illustrations of coverage that you have been presented with, I would be happy to help you.
WCI is right on the money.
In fact, if your goal is to reduce your premium, I would be surprised if MassMutual would be the carrier of choice. Typically, unless you are at a hospital that has a discount plan and occupation class upgrade, MassMutual typically does not price out much better, if at all, compared to Guardian if you are comparing similar benefits and riders.
How are independent disability insurance agents compensated?
All insurance agents will be compensated through a commission – regardless of whether an independent or not.
The hope in working with an independent agent is that he/she will provide you with unbiased information and advice, helping you find the policy that best fits your needs and interest.
However, the challenge of finding a good agent isn’t quite so simple as working with an independent. There are plenty of truly independent agents who make inappropriate and self-benefiting recommendations, just as there are non-independent agents who are completely unbiased and always looking out for the consumer’s best interest.
The current physician disability insurance market place is extremely competitive. In order to do a thorough job, your agent should be speaking with you about multiple options (MetLife, Guardian, Standard, Principal, Ameritas, etc.). If not, it may be a good idea to get a second opinion.
Which would be the best policy for foreign residency coverage. MasMutual Radius and Standard Protector+ seem like good options. The price difference is at least 25%. Can somebody explain the main difference in the residual disability rider/recovery benefit between these two policies? Is there a reason for concern the fact that the Standard Protector+ policy might be discontinued in all the states.
Jesus C, Which state are you in?
I want to get disability insurance and have read several of the articles on your site.
How do I go about getting it?
Do I have to go find an agent who deals with several companies. Do the companies allow purchases directly from them and will they give me a break as they do not have to pay commission to an agent?
You have to buy insurance from an agent, might as well get the benefit of using a good independent one. I would trust any of the agents advertising on the blog to sell me the right policy for me.
Disability insurance carriers do not sell their products directly to the public.
I work with all of the top carriers, am insurance licensed in every state, and have access to discount programs across the country.
I you send an email to [email protected], I would be happy to help you.
A few agents have mentioned to me that Ameritas guarantees your “rate and discounts” for any exercise of your future purchase option, but Guardian does not.
What does that mean? and how have the rates changed over the years?
When you exercise an increase option, some carriers simply amend the schedule pages of your existing policy. As such, all policy provisions remain the same, including any applicable discounts, using the rate book that was in effect at the time of the original purchase. The rate for the additional coverage, however, will be based upon your age at the time of the increase option exercise.
While Guardian guarantees the occupation class and risk class based upon the original policy, a new policy is issued.
As such, the rate book and contractual provisions for the increases coverage may not be the same and you may not qualify for the same discount that you had on the original policy for the new coverage.
Ameritas does issue new schedule pages with a new policy number but all else remains as described above.
Generally, the rates have remained stable. However, for example, if you originally purchased a Guardian policy with lifetime benefits a few years ago (when it was a good deal and inexpensive) and now were exercising your FIO Rider, the cost of the new policy would be substantially more expensive due to the increase in the cost of the lifetime benefit period.
This would not be the case for Ameritas or a carrier that amended the existing policy to reflect the increase in coverage.
Hi Lawrence and WCI,
I am a female anesthesiology resident. I recently applied for a Principal policy with medical underwriting. However, due to preexisting conditions (that are benign/asymptomatic and/or resolved and a non-issue), I was denied the future purchase option rider to increase my coverage after I graduate in June of this year. I found out about the Standard Guarantee Issue program and have since applied. I was told by my independent insurance agent that if Principal denied me future additional coverage, my best bet was to get the Standard Protector + GI policy in PA. Is the Standard policy really my best option, or should I look into other companies? Is the Standard GI policy comparable to the comprehensive policies offered by Guardian, Metlife, etc? I will be paying around $340 monthly. My fellow residents who are healthy females and a couple years younger than me are paying $150, which I find to be a huge difference. Is that because of the medical underwriting? Thank you so much!
Catherine-
As a female physician, your best options in terms of cost is Principal. Your best option in terms of underwriting, based on your prior medical history, would be Standard’s GSI Plan.
However, as an anesthesiologist, with Standard, you are in a very unfavorable occupation class (2P). As such, you pay a 25% higher premium compared to all other medical specialties.
Was the Principal policy issued with benefits payable to age 65? Were just the FBI and BU Riders removed? Did the underwriter say that they would reconsider and potentially add them back in the future?
Keep in mind that as a graduating anesthesiology resident (“New In Practice” Anesthesiologist), you automatically qualify to purchase up to $6,500 month regardless of your earned income or future employer provided coverage, if any. Did you apply for that amount?
Do you have a signed employment contract with a guaranteed salary or will you be paid entirely on production? Will your future employer be providing you with any Long-Term Disability coverage when you start working? What is the maximum monthly benefit on the group LTD plan?
If you qualify for more than the $6,500 month, you can either purchase an additional policy from Principal to make up the difference or simply do an adjustment application using the same blood and urine tests that were already done (they are good for up to 12 months) and answer health questions (and if soon enough, most likely things would not have changed) to increase your monthly benefit.
If you want to discuss things in more detail, feel free to call or email me as I would be happy to help you make a decision as to what is best for you based on your individual circumstances (which is probably more than you want to put in the comments section of the blog).
Hi Lawrence,
Do you review current disability policies that are already in place? I have one but I’m not sure if I bought the right product. I only spoke to one person–perhaps, drank the cool aid too quickly in residency.
Hi,
I am curious about the definitions of partial disability for principal vs mass mutual. Mass mutual seems to be purely loss of income while principal seems to be loss of income PLUS loss of time or duties. Is my idea correct? If so, principal would make me worried because an injury could occur which may slow my work, but not stop me from performing my duties/working full time, which may not allow me to be considered partially disabled. I am a recently graduated dentist and am trying to lock in a policy in the next week or two.
Thanks,
Zach
Zach-
MassMutual’s policy states that The Extended Partial rider provides a disability benefit if the insured is working, but as a result of a disability, suffers at least a 15% loss of income compared to pre-disability income.
For the first 6 months of partial disability, an income loss is not required.
The insured is considered partially disabled if working, but due to disability, cannot perform the main duties of his/her occupation for no more than 85% of the time or has a 15% income loss compared to pre-disability earnings.
Principal’s policy states that If you are residually disabled under the terms of this rider and lose at least 20% of your prior earnings due solely to an injury or sickness and you are able to perform some, but not
all, of the substantial and material duties or you are unable to work full time in your occupation or you are working in another occupation, you’ll receive a benefit proportionate to your loss.
So, other than for the first six months of an Extended Partial/Residual claim where MassMutual does not require an income loss the policies are very similar.
MassMutual is stronger in that they require a 15% loss of income compared to Principal’s 20% to trigger Residual Disability benefits. MassMutual also replaces dollars lost for the first 12 months of an Extended Partial claim (up to the policy’s maximum monthly benefit).
After that, both policies both pay benefits proportionate to your loss of income and both include a unlimited Recovery Benefit (if you are back to work on a full-time basis but still have a loss of income due to your prior disability). This would likely be a result of your patients going elsewhere and/or your prior referral sources referring to another dentist or dental specialist.
Hope this helps.