By Dr. Tyler Scott, WCI Columnist
The moment when everything changed.
“Dr. Scott, I can’t get the handpiece positioned correctly to refine this distal-lingual chamfer on #3 for Gladys. Can you help me?”
It was just another Tuesday teaching at the dental school. SRPs in two chairs; a three-ring circus of a pedo exam in another; two no-shows; and a crown prep for Gladys who, at 74, had finally lost the battle of biting into Jolly Ranchers daily and had fractured the functional cusp off of her upper right molar.
“Yeah, I’ll be right over,” I said.
I put down my laptop where I had been taking what felt like the 387th mandatory HIPPA training of my life, grabbed my loupes, and headed over to help an enthusiastic albeit overwhelmed junior dental student doing her first crown ever on a live patient.
“Oh, that’s why you can’t see anything,” I said. “You need to have the patient completely supine to get back there, and you can’t be sitting at 9 o’clock. It’s impossible to see if you have her up at 30 degrees and you have to move over to the 11 o’clock position.”
I laid the patient back, swung around to the top of the chair, and showed the sweaty student how to position herself and fulcrum correctly to easily see and refine the area in question.
“Do you want to do it, or do you want me to touch it up for you?” I asked (we were almost three hours into the appointment. There is a reason dental school fees are lower than private practice fees.).
“You do it,” said Gladys and the student simultaneously.
I reached over to grab a new 856-016 bur, and as I turned back to position myself again, I leaned forward just slightly and . . . BAM!!! I winced violently as I felt an intense stabbing pain in my lower back. It felt like someone hit a screwdriver with a croquet mallet from my lumber spine toward my left hip. I flinched so obviously that the only other thing I could hear above the screaming pain was the sound of my own embarrassment. I was mortified. I was sure the patient saw me recoil and grimace, but alas, Gladys had her eyes closed.
“Oh, I wouldn’t want to rob you of the educational opportunity we have here,” I said. “You’ve done great so far; this will only take a minute or two to finish up.”
What the heck was THAT?!?
The Diagnosis, Part 1
Like any dentist, my neck and back had bothered me at times in my career. I had made an inconsistent yet genuine effort to practice good ergonomics, to stretch during the day, and to take care of myself during the week. I had even been getting twice-monthly massages and going to the gym with the purpose of strengthening my core.
But this was no achy back. Something felt wrong, really wrong.
After a trip to my PCP and some functional testing later, a differential diagnosis started to form. Ankylosing spondylitis, piriformis syndrome, and disc prolapse were some initial suspects. Blood work was done that day to check for a specific gene associated with ankylosing spondylitis, an MRI was ordered for a few weeks later to look at the soft tissue, and I was referred to physical therapy to start working on stretching and strengthening the supportive postural muscles in my lower back.
I hoped that I would be getting a definitive diagnosis soon which would lead to a successful treatment plan, but I left there feeling a bit nervous when my doctor asked, “Dentistry, huh? This doesn’t always end well for you guys. Do you have a disability policy?”
More information here:
Fortunately, I had been reading The White Coat Investor long enough to know I needed a true own-occupation long-term disability insurance policy. Shortly after graduating from dental school, I got a policy in place with all the qualities Dr. Jim Dahle has taught me to look for: non-cancelable; guaranteed renewable; and riders for partial disability, cost of living adjustment, and future benefit increase option.
The benefit was for 60% of the income the contract from the public health clinic showed I would receive in my first year. I was now the proud owner of a $5,400 per month quality long-term disability policy.
As my income increased in the coming years, I would send in my W-2 and increase my coverage accordingly. However, that also increased the premium. Once I got to $7,000 per month of coverage and the premium was $2,500 per year (up from ~$1,800 originally), that check got increasingly painful to write. We had three little kids and a modest public health income, and that $2,500 was a HUGE amount of money for us. And for what? I was young, healthy, and spry—not some fragile old man. I told myself I was done increasing my benefit and paying the profit-mongering insurance scum more and more of my money each year. I stopped increasing my benefit.
Fast forward seven years later, and I was suddenly wondering if I was going to have to file a claim.
I was unsettled. I didn’t know what I should do next, and just like the other moments of uncertainty in my financial life, I turned to WCI. I ended up reading two very helpful posts that had an incredibly positive impact on the end of this story:
One takeaway from these two guest posts, both written by disability attorneys, was to talk to a lawyer early in the process if you think you may need to file a claim. My first thought was that it was a fairly self-serving bit of advice, but I followed it and I’m so glad I did.
I reached out to the offices of both authors of the posts. I first spoke with Evan Schwartz who was incredibly helpful and generous with his time during the free initial consultation. I had previously emailed him my policy and medical records, and he told me that I had a strong case but that I had a potential problem that needed decisive action.
A few months before this, I had been offered a job as a financial planner. I had already started the process of onboarding for this job, which I had originally intended to be a part-time monetized hobby and a possible pathway to a more substantial step back from dentistry. I had even taken on one client as a trial run and had been paid on a 1099 for that work. I had passed the trial phase, and I was about to be added to the payroll of the finance firm as a W-2 part-time employee in only a few weeks.
I fully intended to stay employed by the dental school and to ask to transition to a non-clinical teaching role while I went through my treatment plan.
Evan told me that if I got added to the financial firm’s payroll or if I transitioned to a didactic position within the school before I had clearly “established a date of disability,” the insurance company would argue that my “own occupation” was that of a financial planner and/or lecturer and that my claim would be at serious risk because I was fully able to work in those jobs—even with my back injury.
If I wanted to strengthen my chances of success, I needed something more definitive in my medical records showing that I could not practice clinical dentistry. He told me I needed to get that MRI as soon as possible and definitely before I transitioned roles in the school or signed on as a financial planner. He also told me to be clear and honest with anyone I interacted with who may be writing a note in my chart that I was a dentist, that I couldn’t work, and that I may be filing a disability claim.
He offered to take my case and his firm would take the lead on the rest of the process. The price was a $5,000 retainer. I said I would think about it, but first, I wanted to use my immediate bandwidth to get my medical records shored up.
More information here:
The Diagnosis, Part 2
On Evan’s advice, I immediately called the imaging center and begged to have my appointment moved up. I got in a few days later and then back into my PCP a day after that to review the results.
It was bad, much worse than either of us thought.
A series of bulging discs pushing on my spinal cord; arthritis in my back joints; and, most problematic of all, a severe narrowing of the canals that my spinal nerves run through. There is no consensus why this all happened; the various doctors suppose it was some combination of genetics, dentistry, and bad luck. Regardless of why it happened, I felt old, broken, worried, and validated. I wondered if I was just being overreactive and whiny and if I was just suffering from “man flu of the back.” But at least now I knew I had real structural problems.
For those interested, the radiology report read this way:
- L1/L2 Mild facet arthrosis.
- L2/L3 Mild facet arthrosis.
- L3/L4 Moderate facet arthrosis. Moderate disc bulge with annualar fissure. Mild flattening of the thecal sac. Mild neural foramen narrowing.
- L4/L5 Severe facet arthrosis. Moderate midline protrusion with annualar fissure. Moderate central spinal canal stenosis. Moderate lateral recess and neural foramen narrowing.
- L5/S1 Large-sized disc bulge asymmetric left. Severe lateral recess narrowing. Severe left and moderate right neural foramen narrowing. Modic type I discogenic edema along the endplates asymmetric left.
In the days between the horrifying moment at the dental school and reviewing the MRI findings with my doctor, I hadn’t slept through the night. Partly because I was terrified about what was happening and mostly because these sudden pains would wake me up every hour or two. I could go about my life just fine most of the time, but once or twice an hour, a subtle bend to pick up a fork or a mild twist to buckle my seatbelt would send the screwdriver back through my back/butt/hip complex. It was seemingly random. It was a game of lumbago Russian roulette just to tie my shoes or dry myself off.
It had kept happening at work, but I had taken care not to hold anything other than a mirror in a patient’s mouth and deflected anything potentially dangerous to other faculty. I had to “run to the bathroom” a lot those couple of weeks.
After talking to my doctor about the next steps in my treatment plan, she said, “Let’s talk about work. You obviously can’t do dentistry right now. It’s not reasonable from a pain perspective and it’s not ethical from a patient care perspective.”
I was disabled from my occupation.
More information here:
Evan helped me dodge a major problem. I now had definitive imaging and chart notes to support the reality that I could not be running a drill in anyone’s mouth for the time being and, critically, I had not yet transitioned to any other types of work. My “own occupation” on the date of the MRI and the chart notes was that of a clinical dentist.
I felt so grateful to him and was ready to call him back and pay the $5,000 retainer. But . . . remember how I stopped increasing my benefit seven years ago because I couldn’t swallow paying the increasing premium? Well, that $7,000 benefit no longer represented 60% of my income; it was more like 40%. After years of pay raises and negotiating higher-than-average academic salaries, I was facing the reality of taking a major pay cut to be a didactic lecturer or a flat-fee financial planner. We had recently bought a house in the massively overpriced Salt Lake City market, and we were not in a position to be writing $5,000 checks without thoughtful consideration. We were about to be in a tough financial spot, even if my claim was approved.
That’s when I called Ben Glass, the author of the other post I had read on the blog. For $600, Ben would review my policy and my medical records, and he would provide a one-hour consultation about how to most optimally file my claim. He wouldn’t do it for me like Evan would—I’d have to do it all myself—but he would advise me beforehand.
This was definitely worth the money.
Ben told me that, based on the language in my policy and the clarity in my medical records, my claim was strong. He advised me to lean less on the “it hurts so bad to do dentistry” part of the story and more heavily on the “this is not safe for my patients, and I could really hurt someone” part of the story. The combination of clear medical records with the possibility of patient harm meant that I didn’t need to convince anyone of my pain experience, a subjective finding that anyone who works in medicine knows is difficult to quantify.
I wrote up my narrative to the insurance company with his advice in mind, sent it back to his office for revision, and filed my claim with cautious optimism.
The insurance company was very kind in the days that followed, and at the same time, it became very clear to me that its business model is to take in premiums and do anything possible to not pay out benefits. There were scores of phone calls, emails, paperwork, return trips to the doctor, interviews, and assertions that I was not a dentist but rather a financial planner because I had one paltry 1099 check from a month before my MRI. Then, over four months later . . . my claim was approved. I was told I would start receiving $7,000 every month per my total disability as a clinical dentist.
My disability tale, while still tragic, had a happier ending than it otherwise could have.
Thanks to Evan, I established a date of disability prior to starting as a financial planner, so my financial planning income has not and will not reduce my benefit. I am loving my life now working from home and helping my fellow healthcare providers find peace of mind through comprehensive flat-fee planning.
My back still hurts—a lot. Not as much as it did before, but despite several procedures and many months of physical therapy, there has not been much improvement. The thing that seems to help the most is not doing dentistry. I still twitch violently at work, but now it’s only an Excel formula that gets damaged and not the sublingual tissue of someone I’ve sworn not to harm.
My policy pays out until I am 65, but there is no guarantee that will happen. I will need a physician to recertify my disability each year based on whatever findings are present at the time.
I also have a long-term disability policy provided by the dental school through The Hartford. Despite filing a claim more than eight months ago, I haven't heard anything. Working with that insurance company has been an absolute nightmare. It said that my claim is unlikely to get paid because I was working in one sedentary occupation and moved to another sedentary occupation, so there is no merit to my claim of disability. As if doing a root canal in a 0.2 mm hole bent over for two hours is the same as talking to someone on Zoom about how to execute on their Mega Backdoor Roth. Also, any benefit I get from that policy will be taxable (this is the case with most employer-provided plans), and it would only pay out for two years.
I still have not technically ended my employment with the dental school. I am hopeful that if a future treatment is successful, I can return one day in some capacity and stay connected to this part of my life in a smaller way.
- If you think there is any possibility you may need to file a claim, talk to a lawyer sooner rather than later. If I end up getting $7,000 a month until I’m 65, talking to those attorneys was worth $2.184 million (tax-free).
- Don’t start ANY other work before your claim is made. The insurance companies are paid to not pay you. If there is any income that is not coming from practicing medicine, they will attempt to deny your claim or reduce your payout citing your other occupations.
- Don’t get cheap with your long-term disability coverage. The premiums on these policies are massive and very painful to pay. But they are expensive because there are a lot of claims made. One in seven doctors will make a claim during their career. I never thought I’d be one. If I had increased my benefit through the years, my payment would be $10,500 per month. My unwillingness to increase my benefit may end up costing me $1.092 million tax-free over the next 26 years.
- Don’t rely on employer-provided plans. They often have a more unfavorable definition of disability. The benefits are usually taxable, and they often aren’t portable. Plus, at least in my case, they have been indescribably awful to work with compared to my personal policy.
- Be clear with those writing your chart notes. As I was telling my PCP, my physical therapists, and the anesthesiologists doing most of my pain procedures what was going on in my life as it relates to dentistry and my disability claim, I almost always was told, “Oh that’s good to know, I’ll make sure to be extra clear in the chart about what we see here.” I think that helped; it certainly didn’t hurt.
- Think twice before getting a crown at the dental school.
- HIPPA training has painful outcomes.
- If you love your dentist, dental hygienist, or their assistants, buy them a massage.
Have more questions about insurance and what kind of policies would be the best for you? Hire a WCI-vetted professional to help you sort it out.
If you've had to claim a disability, was your experience similar to mine? What obstacles did you face? Were you ultimately successful? Would you do anything different? Comment below!