Cassie Springer Ayeni Tag

I’m a Physician with a Disability—What Can I Do to Protect Myself?

As a physician, you’re trained to solve complex problems under pressure.  You have worked hard for your career, and probably never expected to have to stop working due to a disability.  Perhaps you applied on your own for those benefits and the insurance carrier denied your claim, or perhaps you’re beginning the process of applying for long-term disability insurance benefits.  What can cause highly educated medical professionals to lose their long-term disability appeals?

It’s not a lack of intelligence. And it’s definitely not because you’re “not really disabled.”

In my work representing physicians and other high-income professionals, I’ve seen a frustrating pattern: doctors who rightfully file for disability benefits are denied just as frequently (and sometimes more so) as people who are not trained in medicine.

Here’s what’s going wrong, and how you can protect your livelihood and your future.

•  Doctors are often treated on an informal basis by their colleagues

Any professional with a large network of trusted colleagues will turn to them first when something in their field goes wrong.  That’s a given, and I get it.  My father was a general practitioner from 1969 until 2021, when he passed away, and he was my first, and often only, phone call when I or my family had a medical concern.  However, these initial, informal phone calls and diagnoses don’t make it into your medical records.  So while you may have a months- or years-long history of seeking medical advice for your ailment, the medical records may look as though you just started treatment for a condition that has now become disabling.  My first task with any of my clients in the medical field is to request their complete relevant medical records, so that I can ascertain how supported their disability is within the records that the insurer will review.  And if those records are incomplete or sparse, I develop a strategy, through declarations, letters, or any other means, to make sure that the true course of treatment is documented in the long-term disability claim file.

• Insurers may use narrow definitions of “Disabled” for doctors

If you’re a surgeon who can’t operate anymore, that may seem clearly disabling to you. But your policy might say otherwise—especially if it’s a group policy through your hospital or medical group.

Many doctors are shocked to learn that their policy allows the insurer to deny benefits if they can do any work in a related field, such as consulting or teaching.

What to do: Get a copy of your full policy—not just the summary. A legal review by Springer Ayeni can help uncover how your “own occupation” is actually defined.

• Doctors may think it’s better to scale back to part-time rather than filing a disability benefit claim

In my experience, physicians and other professionals who have dedicated their lives to developing their expertise through education and practice, are incredibly determined to hang onto even part of their work rather than file a claim under disability insurance policies.  Why?  Because you have worked for your entire life to become a physician, and you may have even set that personal goal when you were just a child.  My father never retired as a physician, and even when he became frail and sick, he kept working, forsaking all else, until shortly before he passed.  For those of us who truly enjoy helping others in our profession, we may not even contemplate retirement, let alone leaving the practice much earlier than expected due to a disability.  

Unfortunately, long-term disability insurers often operate under what I have dubbed the “hit by a bus theory,” where one day you are fully capable of performing your job without limitation, then you get “hit by a bus,” and the next day you are disabled.  Most disabilities are not so straightforward, and many physicians continue working as long as they can with progressive disabilities,.  

If you have strived in your profession for years and years, then your medical condition causes you to lose some capacity, you might start by scaling back your hours, or switching to more administrative tasks.  Before making this kind of career move, please give me a call at 510-926-6768, so I can discuss the strategy of whether you might qualify for long-term disability benefits, and what the impact of switching job duties or reducing hours might be on an eventual disability claim.  

What to do:  Call me to discuss your disability and the terms of your benefit plan as soon as possible so that you can develop a strategy for whether, and how, you might either scale back your duties, file for disability benefits to replace your lost income, or both.  Ironically, disability insurers often scrutinize partial disability claims harder than total disability claims, seeming to punish those who have tried heroically to keep working despite disabling limitations.  I am here to help and advise, and I encourage you to let me help you make an informed decision about reducing your hours or filing a disability claim.

• Medical Records or Treating Physician Forms Alone Usually Aren’t Enough

Insurers don’t just want to know your diagnosis. They want to see how your condition limits your ability to perform your specific job duties.  In the ultimate “gotcha,” however, insurance forms for treating physicians to fill out either don’t ask the right question (“how”) or don’t leave enough room for your doctor to answer that question thoroughly.  Stating an ICD Code and a condition, like “long-COVID,” “Parkinson’s Disease,” “Mild Cognitive Disorder,” “Major Depressive Disorder,” or “Migraine,” etc., is insufficient to prevail on a claim for disability benefits.  You and your doctor need to explain how your condition affects your ability to specific tasks in your practice, such as stand during rounds, hold your arms in the correct position during surgery, respond adequately to emergencies, work a nightshift or be on-call, or manage a high-stress practice.

What I suggest:  Work with your treating doctor to create a detailed functional report—not just a chart note, by writing down a list of what specific job duties are affected by your disability, and going over that list with your treating physician.  It’s best if your medical records can be as detailed as possible about what you are unable to do at work. Also, the boxes on insurance forms are not a limitation!  Put in an asterisk and attach a supplemental page or 2 to submit as much helpful information as possible.

• Doctors Are Prime Targets for Surveillance

High-income professionals like doctors are often watched, because they are expensive claims for the insurer to pay. A short video of you walking, driving a distance longer than your restrictions permit, shopping in a store, or attending your child’s sports game can be twisted to argue you’re not truly disabled.

What to do:  Make sure all of your social media settings are set to “private.”  Be mindful of what you do in public and what your restrictions and limitations are.  Be honest in disclosing your actual activities on forms.  For example, if your physician has recommended exercise to improve your disabling conditions, make sure you state on your application or update forms what you do and why it was prescribed by your doctor.  If benefits have been denied, be sure to request and review all surveillance footage so that you can include context for what was actually happening on that day.  Judges ultimately appreciate context, and understand that there may be anomalous events that do not necessarily mean that you can return to the full-time practice of medicine.  While insurers may be looking for a “gotcha,” have faith that most judges are wise enough to see the big picture. 

• ERISA is brutally technical

The ERISA process has strict rules. You often get only one appeal to submit your evidence, and it must be submitted by a specific date or you lose your right to the claim.  Moreover, if you miss including key documents, you may not have the chance to get that evidence in front of the court if you later go to court.

What to do: Don’t wait until after your appeal is denied to consult a lawyer. The best time to get legal help is before you submit your appeal—when there’s still time to shape the record.  Reach out to me at www.benefitslaw.com or 510-926-6768 and I would be happy to discuss your specific issue with you in more detail.

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The Elephant in the Room: Can AI Really Handle Your ERISA Disability Claim and Appeal?

Why Turning to a Bot for Legal Advice Could Hurt Your Claim—And What You Deserve Instead

Let’s be honest: more and more people are asking AI tools like ChatGPT or Google’s Gemini how to appeal a denied disability claim before they ever think of calling a lawyer.

I get it. AI is fast. It’s available 24/7. It doesn’t require talking with a live person about the difficult details of your health.  And, of course, AI is free or low-cost.

But when your financial stability and health are on the line, you need to know the full truth: AI is not a substitute for experienced legal counsel.  In fact, trusting AI blindly could do more harm than good.

As someone who has spent 23 years representing clients in ERISA disability cases, I’m not here to bash technology.  There is much to gain from the efficiency of evolving technology and I am certainly not advocating AI abstinence.  I am here, however, to lay out the risks, differences, and reasons why having a compassionate, strategic, and knowledgeable attorney matters for something as critical to your financial health as your long-term disability benefits.

Why People Turn to AI—and Where It Falls Short

If you type into ChatGPT:

“How do I appeal a denied ERISA disability claim?”

You’ll probably get something like this:

“Request your claim file. Review the denial letter. Submit additional medical evidence. Write an appeal within 180 days.”  You might even get general “advice” about including medical records and statements in support of your appeal.  However, even AI knows its own limitations.  A common Bot disclaimer goes something like this:

“Generative AI features are not intended for professional advice. Do not use generative AI features to seek or provide legal, medical, financial, or other kinds of professional advice or any opinions, judgments, or recommendations without conducting your own independent consultation or research. Generative AI features cannot replace advice provided by a qualified professional and do not form any such relationship (e.g., attorney-client relationship).” (https://www.adobe.com/legal/licenses-terms/adobe-gen-ai-user-guidelines.html)

Even tech giants know that the disclaimer is necessary because AI advice is not strategic, not confidential, not detailed, and, in fact, is dangerously simplistic.

For example, AI does not, and cannot, analyze whether your plan’s language requires a de novo or abuse of discretion standard of review in court; whether the facts of your case meet the definition of disability under your plan language; whether the insurer has disclosed all required information in its claim file; whether there is evidence of biased claims handling in your file; whether the insurer has calculated offsets accurately in your case; what evidence in the claim file needs to be rebutted in an appeal; what the likelihood of settlement and possible settlement amount in litigation might be.  The list goes on and on.  These are the kinds of distinctions that change the outcome of a case—and they’re not in an AI’s toolbox.  

The bottom line: AI gives you non-confidential general advice.  Springer Ayeni gives you a legal strategy based on decades of experience handling ERISA long-term disability cases.

AI “Hallucinations” and Fake Law: A Dangerous Trend

AI tools are known for hallucinating legal citations—that is, making up case law that sounds real but isn’t. See https://hai.stanford.edu/news/ai-trial-legal-models-hallucinate-1-out-6-or-more-benchmarking-queries  I’ve read up on examples of how AI will generate completely fictitious case references and quotes from decisions that don’t exist.  This isn’t just sloppy, it’s dangerous.

First, if you submit an appeal letter to an insurer or judge citing bogus cases, you undermine your credibility.  Second, insisting that there are cases in your favor when you reach out to an attorney, when those cases are entirely fictious (unbeknownst to you), will make an attorney hesitant to offer to represent you.  Attorneys and their clients should be on the same team at all times. Most importantly, you won’t even know when AI has done you dirty with a fictitious citation, because it often sounds right and the wrong cases are mixed right in with actual cases.  

The bottom line: Legal writing is not just writing. It’s advocacy, precision, and ethics.  AI is still a baby in the world of law, and cannot be trusted to do actual legal research.

AI Is NOT Confidential, and that Can Put You at Risk

AI is not a lawyer. It doesn’t form an attorney-client relationship, as all of the tech User Guidelines state. That means: 

1. There is no legal confidentiality. What you input may be stored, analyzed, or even discoverable later.  
2. You might waive privilege by sharing facts about your medical condition, employment, or insurer.  Moreover, AI remembers your input from search to search, so even if you don’t share all the facts in one session, it may know a lot more about you, your condition, your family, your history, your dreams, and your goals from all of the data you have input in previous searches.
3. There is no duty of loyalty. AI doesn’t protect your interests—it just completes a task.  For example, when Chat GPT conversations are shared, Google produces those conversations as “results” upon a simple search.  See https://cybernews.com/ai-news/chatgpt-shared-links-privacy-leak/ 

As an attorney, I never input confidential client information into AI platforms. Doing so risks ethical breaches and the security of your case. Some lawyers are misusing AI and unknowingly exposing clients. That’s not how I work.

If I use AI at all, it’s only for mundane administrative tasks—not for case strategy, legal analysis, or communication. 

The bottom line: Your trust is sacred. And your privacy is non-negotiable. AI will not protect you and advocate for you like a good attorney will.

A Real Appeal Tells the Real Story—Not Just the Medical One

An AI might focus only on lab results and doctor notes. But I know that winning a disability appeal requires telling your whole story, not just summarizing medical visits.  It also requires understanding the law and how it applies to the facts of your case, and being able to spot and rebut flaws in the insurer’s claims handling and medical reviews.

I listen for and translate the truths that often don’t make it into a medical file, like how your fatigue crashes your productivity by noon, or how your brain fog makes multi-step tasks impossible not just at work but in your everyday life, or how your anxiety prevents you from completing your tasks efficiently, or even how you have good days and bad days, requiring you to rest for days if you have over-exerted yourself on a good day.  

I draw out the details of your daily life, your work history, and your limitations, and I explain them clearly and persuasively to the insurance company. This isn’t something a chatbot can do. It takes time, training, empathy, experience, and sound judgment.

The bottom line: I’m not just reviewing records. I’m building your narrative, filling gaps in the file, rebutting arguments, and fighting for your future.

AI Can’t Show Up for You. I Will.

Some pundits say AI will replace lawyers. I do think that technology can make lawyers more efficient at administrative tasks that take away from time spent on actual cases.  However, the best lawyers, those who listen, advocate, strategize, work as a team with their client, and ultimately are successful in cases, cannot ever be replaced by a bot.   Technology will evolve, but compassion, reputation, and results still matter.

When you retain me, you’re not getting a script. You’re getting:

• 23 years of ERISA disability experience
• Strategic, circuit-specific legal knowledge
• A reputation for success and tenacity among colleagues, insurers, and opposing counsel
• A teammate who sees you as more than a claim number
• A fierce advocate who will not ignore you or reduce you to a piece of datum that will influence future actions

The bottom line: You deserve someone who understands not just the law, but the weight of what’s at stake. You deserve someone who knows how to get results and treats you with dignity along the way.

Final Word: Don’t Trust a Bot with Your Livelihood

AI has its place, but not as your attorney. Not when your disability benefits, your financial survival, and your mental and physical health are on the line.

Before you go down a rabbit hole of chatbot answers, talk to someone who’s been through this hundreds of times, someone who won’t hallucinate law, who respects your privacy, and who knows how to win an appeal, not just write about it.

Contact Springer Ayeni today. Let’s protect what matters most—your income, your dignity, your future.

Springer Ayeni: Compassion. Reputation. Results.
www.benefitslaw.com

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ERISA Disability Traps & Tricks for the Non-ERISA Practitioner

By Cassie Springer Ayeni, President Springer Ayeni, A Professional Law Corporation

The Employee Retirement Income Security Act, better known as ERISA, is referred to by at least one judge as “Everything Ridiculous Imagined Since Adam.”  Florence Nightingale Nursing Service, Inc. v. Blue Cross and Blue Shield, .832 F. Supp. 1456, 1457 (N.D. Ala. 1993), affirmed, 41 F.2d 1476 (11th Cir. 1995) (Acker, J.).  It gets its sordid reputation from its limited remedies, roots in trust law, and limited discovery rules.  Yet ERISA is so vast that every lawyer should know a little bit about it.

Most practitioners know that ERISA covers employer-sponsored retirement plans, yet few realize that with minor exceptions[1] it also governs all employer-sponsored health plans, disability benefit plans, and life insurance plans.  29 U.S.C. § 1002.  Of these categories of ERISA litigation, disability benefit lawsuits comprise 64.5% of ERISA litigation, health care accounts for 14.4% or ERISA litigation, and pension just 9.3%.  Anderson, S., ERISA Benefits Litigation: An Empirical Picture, 28 ABA J. Lab. & Emp. L. 1 (2012) at p. 7.  Why is that?  Though ERISA was originally designed to protect pension claims, more and more employers are eliminating traditional pension plans for employees or have outsourced to fiduciaries, and ERISA provides limited relief for breaches of fiduciary duties.  Health claims are notoriously mishandled (we all probably have our own examples of that!), yet if a plaintiff brings an ERISA claim for denied health benefits, the remedy is that the medical provider gets reimbursed, and there are no punitive, compensatory, or consequential damages available to the plaintiff.  Disability benefit claims, however, are another story.  If a worker with an employer-sponsored disability benefit plan files a claim for benefits, that claim is typically administered and paid for by an insurance company.  And because these insurers have a financial conflict of interest, many disability benefit claims are denied despite the claimant’s doctor’s decision that the claimant should stop working.  The remedy under ERISA is payment of the disability benefits through the date of judgment, and benefits can potentially continue until retirement age.  In other words, disability benefits are worth a lot over the claimant’s working lifetime.  That’s why a little ERISA knowledge comes in handy for any practitioner.

 

Screening for ERISA

First, in screening these calls from potential clients, be aware that some issue spotting will be incredibly valuable, as most individuals do not even realize that their claim for disability benefits is governed by ERISA.  Most individuals call with an assumption that the appropriate area of expertise is disability discrimination, workers’ compensation, Social Security disability, or California state disability insurance.  But if the employer offered a disability plan, it is ERISA help they need.

TRAP #1:  Assuming that the potential client knows what kind of attorney she needs for her disability issues.  TRICK #1:  Simply ask “did your employer offer a disability benefit plan?”  If so, ERISA will probably govern.

 

Severance Waivers of ERISA Claims

Second, many people with disabilities may contemplate quitting their job for performance issues or have already been told they will be terminated.  If they are getting close to retirement age, they may assume that an early retirement is the honorable way to exit the job.  The disabled worker may be offered separation or severance pay, but many standard separation or severance agreements actually waive all claims under ERISA!  If someone could potentially obtain a monthly disability benefit until retirement age through their disability benefit plan, this is an extremely valuable benefit to waive in exchange for severance.  Indeed, the prudent plaintiff’s attorney should routinely screen for disability if negotiating severance, as no one would want to give the green light for waiving hundreds of thousands of dollars in disability benefits in exchange for a little severance.

TRAP #2:  Failing to edit out a waiver of ERISA claims.  TRICK #2:  Carve out any claims for disability benefits, health benefits, or pension benefits that might arise under ERISA.  An example of a good carve out is:  “However, the following claims are specifically and expressly excluded from the foregoing Release: (i) health insurance benefits under ERISA or the Consolidated Omnibus Budget Reconciliation Act (COBRA); (ii) claims with respect to benefits, including short- and long-term disability benefit benefits, under a welfare benefit plan governed by the Employee Retirement Income Security Act (ERISA); or (iii) claims with respect to vested benefits under a retirement plan governed by ERISA.”  Most employers understand the practicality of this, particularly because such claims are usually (but not always) filed against the disability insurer, not the employer.

 

Strict ERISA Deadlines

Third, although it is best for the potential client to find an ERISA attorney before making the decision to apply for disability benefits, most do not.  Rather, most potential clients try to find legal help only after the insurer has denied the claim for disability benefits.  At that point, ERISA’s Regulations prescribe a 180-day period for appealing the denied benefit claim.  This process MUST be completed or else the claimant loses the right to file suit, also known as “failure to exhaust administrative remedies.”

TRAP #3:  Failing to submit an appeal of an adverse disability benefit decision within 180 days of receipt of that decision.  TRICK #3:  Don’t miss this deadline!  But if all else fails, immediately call the insurer to request an extension.  ERISA’s regulations allow for “at least” 180 days, but it is up to the insurer to allow an extension.  If granted over the phone, immediately follow it up in writing and indicate a date by which the claimant will submit the appeal.

 

Evidence in the Appeal

Fourth, although filing a hasty appeal is all that is necessary to preserve the ability to file a lawsuit, a scant appeal letter will not win the appeal, nor will it enable an ERISA practitioner to take the case for litigation.  ERISA disability litigation is limited to the factual evidence presented in the aforementioned administrative appeal.  Once in court, in all but rare circumstances, there will be no depositions, further medical records, or opportunities for direct or cross-examination.  And there are also no jury trials.  So if you help someone with their disability benefit appeal, please be sure to include all evidence necessary to win the case down the road.

TRAP #4:  Assuming that there will be a chance in court to put in more evidence supporting the disability claim.  TRICK #4:  Throw in everything but the kitchen sink into the appeal!  If you think the evidence might be useful in litigation, put it into the appeal.  Declarations from the client, friends, family, medical providers, and colleagues, as well as all relevant medical records and expert reports, are key to submit in the appeal of a denied claim.

 

Filing an ERISA or ERISA-Related Claim

Finally, if you do decide to litigate an ERISA claim, be aware that these claims must be brought in federal court or you will face removal of the ERISA claims and all claims related to the ERISA claims.  With limited exceptions, if you are bringing state law claims and ERISA claims, ERISA will preempt those state law claims.[2]

TRAP # 5:  Failing to separate any state law claims from ERISA claims.  TRICK # 5:  Don’t even mention ERISA or other employee benefits or benefit-related remedies in your state law complaint.  Leave the ERISA claims alone and litigate those separately as ERISA claims in federal court, or face removal.

 

TRICK #6:  Give me a call.  I’m an ERISA nerd and I’m happy to field your ERISA questions!  510-926-6768 Option1, or cassie@benefitslaw.com

Cassie Springer Ayeni is the President of Springer Ayeni, A Professional Law Corporation, in Oakland, CA, where she focuses on ERISA disability and life insurance cases. She can be reached at cassie@benefitslaw.com or www.benefitslaw.com

[1] Those exceptions are for public employees (anyone who works for the government such as teachers, legislators, public safety officers, etc.), and “church plans,” (anyone employed, even tangentially, by a religious organization including those who work at Catholic hospitals).

[2] ERISA’s “savings clause” provision saves from preemption any law that regulates insurance, banking, or securities. ERISA § 514(b)(2)(A). An example of the application of the savings clause is in California’s “notice prejudice” rule, which provides that claims can proceed even where there is late notice unless the insurer is prejudiced by the late notice. Because this is a law that regulates insurance and does not provide a remedy that conflicts with ERISA, the law is not preempted. UNUM Life Ins. Co. of Am. v. Ward, 526 U.S. 358, 373, 119 S. Ct. 1380, 1389, 143 L. Ed. 2d 462 (1999).

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