PLEASE READ THE WHOLE POST.

This took weeks of picking and testing mods
Played on PS5, should work on PS4
Order is stable, no crashes
New game on survival difficulty required
All 6 DLCs needed
No unbalanced cheat mods added
Very difficult but satisfying and immersive
Adding other mods will break stuff, ask in comments
Not tested on PS4 or PS4 Pro performance-wise

OVERVIEW

This modlist is for people enjoying difficult challenge, exploration, combat, managing settlements and a bit of building. No more bullet sponges, loot/enemy respawns and rambo playstyle!
In the beginning you are no one. You leave the vault weak, tired, with barely any gear. Avoid most encounters and quests at the start. Try to survive, build a safe spot and carefully explore. Be aware of your surroundings, use what you find.
Saving often in beds and making 'autosave drug' at the earliest possibility is a good idea (nearest chemistry workbench is at Abernathy Farm). Save menu is always on top of MISC category in Pip-Boy.
Discovering new places gives plenty of exp in the beginning, but quests are your main exp income.
Exploring safer areas like Sanctuary, Concord and smaller settlements first (avoiding powerful enemies) recommended. There might be a lot of combat in the background. Don't engage much, especially avoid supermutants, robots, turrets, bears - they are deadly even for high level, well developed characters. Raiders also hit hard, depending on their weapon and rank.
Weapon caliber makes huge damage difference. 10mm is pretty weak, but if you find rare .50cal rounds or some good explosives, you should eliminate tougher targets much more easily.
Investing in stats right after level 15 is a good idea. STR for carry weight, PER for accuracy, END for health, CHA for better prices, INT for more exp, AGI for sneak and speed, LCK for dmg and loot. Be sure of your choices. Watch out for 'revealing all map markers' and 'slow time when aiming' perks. Be sure you want and like them, there is no going back.
Deathclaw in the early minuteman quest is tough - try to use explosives to break his legs and some high caliber weapons to finish him off by shooting his face. Or maybe you'll get lucky and raiders will kill him. Or just simply avoid him until you get proper gear.
Don't waste ammo on zombies, use melee. Bullets are valuable. However zombies can grab and instantly kill you if your HP is very low, so watch out on low, early levels!
Aim for the head for much higher damage. Concentrating damage on arms or legs to rip them off is a good strategy too. Raider without arms wont do much to you except running around and alerting nearby enemies, that is.
Damage types are important. Ballistic damage is not efficient against turrets, melee against radroaches and so on. You need to figure out yourself whats best strategy.
Develop and protect your settlements, put walls to protect generators and other important structures. Repairing is costly. Gear up settlers. Scraping and cleaning settlements is a good early source of components.
Try to fully explore the map, kill enemies and do all quests. Most loot and enemies wont ever respawn so this is your chance to find new secrets in Commonwealth and clear the place.

========== CHANGES ==========

Combat, Enemies

• Enemies will flank, charge, take cover, run in fear, use and pick up ammo & weapons, swap to backup gun and so on.
• Headshots or weakspot hits do much higher damage than torso shots.
• Gun caliber greatly affects damage, explosives are powerful and damage type matters.
• Foes have special moves like biting and holding leg, wrestling moves, kicks. Dependent on enemy type and briefly stuns you.

Sound, Graphic

• Sounds are less flat because of added reverb and other tweaks.
• Very dark nights with wide, helpful flashlight.
• Atmospheric lightning: beautiful light from lantern and fire sources, dusk, dawn, moon, plus bullets illuminate environment when flying around.
• No dreadful, annoying, unimmersive: combat music, hearthbeat, sounds of generators, turrets, exp gain sound, most perk triggers and perk chart.

Crafting, Modifying

• Making/disasembling ammo and also creating various shipments. Upgrading clothes, rings, glasses in different ways.
• Legendary swapping, crafting legendary effects using technical documents. Some effects have been adjusted.
• Added crafting of new, lower damage explosives, but they have unique effects for ease of use.

Perks, SPECIAL

• STR affects carry weight, PER accuracy, END is health, max AP, CHA for better prices, INT for more exp, AGI for sneak, walk and reload speed, LCK for small dmg boost, loot, critical hits outside VATS and while using it.
• Leveling up does not give you health. You rely on stats, bonuses, gear.
• Perks tree mostly changed, level 15 needed to start increasing Special base stats, level of around 100 to increase stat to 10. To get all perks you would need 300 levels, so new modified 'idiot savant' will help a lot.
• Collecting magazines, bobbleheads, companion perks is now more helpful and recommended.
• Some skills are changed, reordered, much more interesting and useful.
• More perks are needed for crafting, especially science perk is required for most technology related stuff.
• Lockpicking everything is available instantly from level one, but perks and AGI make it reasonably easier. Bobby pins are more rare.
• Hacking is simplified to not do the repeating minigame. Now holotapes to reprogram and override terminals might be of use.

Settlements, Building

• Expensive build costs of robot workbenches, turrets, big generators, so buying component shipments is justified.
• You can hire guards for caps or risk settlers lives on the usual guard posts.
• Can't harvest planted fruit and veg, you get your fair share in workbench instead.
• Collecting resources by settlers changed. Bigger variety of settlers and they are now mortal.
• More objects to build and decorate your bases.

Locations, Loot

• Items like meds and ammo are harder to find and exist in appropriate containers.
• New map markers and few minuteman towers as a small addition to explore.
• Quick travel available, but only to settlements.
• Only rare enemies like bosses drop legendaries. And many more...

Before you download:

• Safe to remove/swap mods are listed below the modlist, just in case you don't like or want some of them. Rest needs to be kept for balance or glitch removal, but only in the CORRECT ORDER!
• Remove all mods you currently have before downloading this mod list.
• Read what to do after downloading mods.

MOD LIST WITH CORECT ORDER:

1. Unofficial Fallout 4 Patch [UFO4P] [PS4] - Thousands of small bug fixes for FO4.
2. Radium Rifle Suppressed Sound Fix - As the mod name suggests. Must be on top of mod list, its a master file.
3. [PS4] Pip-Boy Paint Jobs - Colors Of The Wasteland Pack (Club Freedom) - Adds simple Pip-Boy skins. Remember you can click touchpad while using pip-boy to zoom. Again a master file.
4. Kane's Items Sorting (PS4) - Junk is sorted and some other things too.
5. [PS] Useful Technical Documents - Legendaries - You can swap legendaries for free, create new ones using technical documents.
6. Named NPC Protection [PS4] - Protects named quest npc's, merchants, important characters from random encounters with enemies.
7. Tribals of Commonwealth - Adds tribal groups, often found in wilderness.
8. Ghouls Of Commonwealth - Adds over 1100 feral ghouls for zombie apocalypse and chaos.
9. DLC Creatures In The Commonwealth [PS4] - Adds 200 creature spawns to the commonwealth for constant war, danger and chaos.
10. Longhorns Of The Commonwealth - Adds longhorns to more empty areas on the map.
11. Gulpers Of The Commonwealth - Adds gulpers to more empty areas on the map.
12. Wolves Of The Commonwealth - Adds wolf spawn points to the map.
13. More Behemoths In Commonwealth - Adds 5 more behemots to the Commonwealth.
14. Behind Enemy Lines - Adds plenty of enemies to the glowing sea region.
15. Roving War Parties, Raiding Packs And Hordes Of MY - Adds wandering groups that attack some key locations.
16. More Radstags - Adds plenty of radstags, especially north and into forests.
17. Better Radstags - More agressive radstags.
18. Not a Princess - Humans can grab you/others and slam on the ground, make karate moves, dogs can hold your legs/arms, bloodbugs suck your blood.
19. Disable Minutemen's Annoying Quests [PS4] - Disables 7 types of repetitive and not important radiant quests.
20. [PS4] Grounded Updated By Sarinia - Adds tons of ground foundations, floors, walls, mounds of dirt to Structures-Concrete menu.
21. Miscellaneous Settlement Items Unlocked [PS4] By Callias - Adds 49 objects for building in settlements.
22. Cinder Block Walls And Sandbags Unlocked [PS4] By Callias - Adds 16 objects like cinder blocks and sandbags.
23. Constructible Faction Guards - Adds ability to hire guards for caps in build menu, but only after allying with a faction.
24. [PS4] OCDecorator - Adds inventory items as a decorational building objects.
25. [PS4] OCDecorator DLC - Support for addons for the above mod.
26. Tweaks - Survival Fast Travel Settlements All DLC - You can fast travel to settlements on survival difficulty.
27. 1st Person Animation Tweaks [PS4] - In first person mode you lower your gun automatically.
28. [PS4] Swinging Animated Meat Bags - Adds animations to supermutant meat bags.
29. Power Line Physics [PS4] - Swinging power lines in settlements.
30. No Sneak Indicators - Completely removes all sneak indicators.
31. [PS4] Dogs Not Brahmin - Provisioners and traders use dogs instead of brahmin.
32. Vertibirds Unghosted - Tweaks invincible vertibirds for danger and realism.
33. [PS4] Simple Settlers (Mortal Edition) - Provides bigger settlers pool (five times more) and names them.
34. Quieter Settlements PS4 - Vanilla - Generators, turrets and hammering are much quieter.
35. Fallout 76-Style Region Music - Changes music in regions for less boring/repetitive background tracks.
36. Reverb And Ambiance Overhaul - ALL DLC [PS4] - Tweaks sounds for better ambient and reverb and adds sliders to options.
37. Better Dialogue - Camera focuses on NPC, changes made to some irritating generic dialogues and tweaked dialogue interuption.
38. Esk QuietPerks [PS4] - Muted five annoying perks like idiot savant.
39. No Experience SFX - Silences sounds when gaining experience from various sources.
40. [PS4] Dead Beat - Removes heart beat sound at low HP.
41. Combat Music Remover - Mutes combat music, so there is silence and suspension when enemy detects you.
42. Commonwealth Visual Overhaul & DLC [PS4] - Changes colours, atmosphere and makes nights darker.
43. UCW - Unified Commonwealth Weather - Adjusted weather for regions and integrated DLC weather for Commonwealth.
44. [PS4] No More Fake Puddles - Removes ugly puddles that stay 24/7.
45. No More Twigs - Removes stupid twigs sticking out of the ground.
46. [PS4] Enhanced Flickering Firelight - Better light effects for fire sources including oil lamps.
47. [PS4] Dark Mode - Abandoned Settlements - Empty settlements don't have light sources.
48. Vanilla Moon (4x) - Much bigger moon. Anything bigger looks low quality.
49. Sunlight Alignment Tweak - Better Dawn And Dusk [PS4] - Changes sun and moon movement for better lighting and atmosphere during dusk, dawn and night.
50. Crafting Blur Removal (PS4) - Removes blur while looting containers, from crafting screen, power armor.
51. Ironsight Blur Removal (PS4) - Removes blur while aiming.
52. More Map Markers (PS4) - Adds some new markers on map.
53. CleanVATS - Green Tint Remover PS4 - Removes fullscreen green tint effect while aiming in VATS mode.
54. VATS Third Person Only - As the name says, just changes in cameras used in VATS.
55. [PS4] Payneful VATS - Better VATS cinematics, shows important hits and finishers a bit slower.
56. Component Tagging Helper - Allows to easily tag basic components on cooking bench and you can quickly view how many you have in total.
57. Grenade and Mine Pack - Adds some new weaker, but modified explosives.
58. Saving Survival Mode - Allows crafting misc items on chemistry workbench for anytime saving (3 standard autosave slots and 1 save shared/overwritten on all survival characters).
59. Animations Be Gone - Removes plenty annoying hammering spots in sanctuary.
60. Minuteman Watchtowers - Adds 8 minuteman watchtowers containing loot and/or guards.
61. Power Goggles (All DLC) - Power Armor Mods For Goggles, Visors, And Glasses - As the name says. Two mods for glasses for high level characters.
62. Clothes For Every Stats Wz - Most clothes can be worn under armor and you can upgrade them after unlocking ballistic weave.
63. Bear Trap and Caltrops Fix [PS4] - Small changes in how traps work and balance them.
64. See-Through-Scopes [PS4] - Adds new combat scopes in place of 2.5x and 4x magnification.
65. See-Through-Scopes - Nuka World [PS4] - As above but for 2 Nuka World guns.
66. See-Through-Scopes - Far Harbor [PS4] - As above but for 2 Far Harbor weapons.
67. Targeting Sensors On Recon Scopes(Colour Coded NPCs Version)[PS4] - Modified recon scopes that highlight enemies, friends and dead bodies in specific colours.
68. Immersive Gameplay Combat Mostly PS4 - Core of this modlist. Hundreds of changes.
69. Immersive-Gameplay. Low Tech, No Powerarmor Justification Patch. (PS4) - Makes fusion cores worn. Balances the game around power armor.
70. Immersive Gameplay Seasonpass Patch (Playstation) - DLC compatibility for IG.
71. Immersive Gameplay Rough Start (PS4) - Overwrites starting level to 1.
72. Medium Settlement Raids PS4 - Makes enemy raids less ridicolous and balanced.
73. Zombie Walkers (PS4) - Most feral ghouls act like slow rotten zombies.
74. Curse Of Darkness - Normal Edition - - Zombies are faster and more dangerous after midnight.
75. Esk No More Teleporting Creatures [PS4] - Molerats and radscorpions don't teleport.
76. Realistic Insects Health [PS4] - Makes insects easier to kill and balanced.
77. Full Load - Loot Logic And Reduction Complete - Restricted harvest, lower and/or different production output for settlements, empty bottles renamed, Scrounger perk less ammo, less meat, less loot.
78. Full Load - Rough Start Less Handouts - Removed some workbenches in starting locations. Different loot in Vault111.
79. Immersive Gameplay Dismemberment - A Patch Or Standalone Feature. - Higher damage to headshots, easier to dismember limbs.
80. Tackle! Immersive Gameplay Knockdown Version - Lets you stagger enemies by sprinting into them after aquiring a perk.
81. Wasteland Baubles Ring Overhaul! PS4 - You can find unique rings at traders, in suitcases, cabinets. Allows scraping and modifying rings for special legendary effects.
82. [PS4] STS - All-In-One - Allows scraping almost all settlement objects.
83. (PS4) Improved Lighting Ballistics - Improves lighting for projectiles such as bullets, lasers, gauss, plasma, missiles, flares and explosions.
84. Explorer Restored - Cut Perk Mod PS4 - Adds rank two of VANS perk - explorer. Uncovers map.
85. Idiot Savant & Better Criticals Redone (PS4) - Idiot savant is better the more INT you have, muted perk chart, better criticals perk for crits outside VATS.
86. Realistic Death Physics - No Animation - ALL DLC [PS4] - Decreases the amount of force of both melee and ranged attacks, so bodies wont fly away.
87. Increased Settler Limit - Awareness - Wire Length - Corpse Collisions [PS4] - More aware settlers with limit of 50 per settlement and longer wires. Mind the limit.
88. Settlement Attack Spawns Outside The Settlement PS4 - Moves attack spawns outside the settlements.
89. Power Conduits Radius Increase And No Build Limit - All DLC [PS4] - Infinite build limit and two times longer range electricity conduits.
90. [PS4] Creation Club Skins (Weapon & PipBoy) Generic Compatibility Patch - Makes weapon paints from Creation Club show up in crafting menu if you have any.
91. No Affinity Cooldown - Removes cooldown between companions liking/hating your actions.
92. [PS4]More XP Per Level (Base:600, Bump 120) - Increased experience required to level up.
93. Increased EXP - Increases the amount of EXP gained to make Immersive Gameplay and mod list balanced.
94. No Building Houses XP Gains PS4 - Building settlements don't provide experience.
95. Pip-Boy Flashlight - Pipboy light is now a flashlight.
96. PS4 - Longer Headlamp Light - Makes flashlight much bigger and changes headlamp and power armor light.
97. [PS4] Starting SPECIAL = 7 - Changes starting SPECIAL stats to 1 in each category so you start weak.
98. No Enemy Respawns - Game areas don't respawn loot and enemies, after time have passed.
99. Accelerated Fast Travel - Fast travel takes less in-game time, should be also relevant to survival needs.
100. Time Scale Changed From 20 To 10 [PS4] - Day and night lasts twice as long.

Additionally after downloading:

• After installing the mod list, restart your PS4/PS5.
• Dont add or remove mods mid playthrough.
• Change game difficulty to survival in options.
• Play on performance 60fps. Newly added mode visual 60fps is more laggy and has awfull VATS framerate.
• If you want even more immersive settings, go to Settings, Gameplay and turn off quest markers or crosshair.
• Go to Options, Sound and reduce ambience level by 5-8 clicks and reverb by 2-3.
• Dont forget to change camera sensitivity (I play on max), next go to Options, Display and change hud color to blue or any other that makes sense (not red), lower transparency by 30% or more, set pip-boy colour to your preference (I use red pip-boy and minty hud to have the best compatibility with highlighting perks and scopes).

You can add/swap some mods if you want:

101... Immortal Cats - PS4 - Invincible cats, so you don't lose happiness increase when they die. Add after mod #83 \ 102... [PS4] STS - Extras - Living & Dead - Season Pass Version - You can get extra resources from scraping dead bodies in settlements. Watch out not to scrap someone alive. Place after mod #82. \ 103... Josephine Preset - Nice looking preset number 13 for female character creation. Change hair and other details if you want. Delete after leaving vault111 and saving (if you need mod list space that is). Add after mod #55. \ 104... Faster Positive Affinity For Companions - Removes cooldown between companions liking/hating your actions and gain five times more positive affinity. Swap with mod #91 if you want more cheaty version. \ 105... Silent Main Menu - To mute main menu sound, find duplicate sound slider named 'Master sound' and move it all the way to the left. Add after mod #41. \ 106... Quieter Settlements PS4 - Contraptions DLC - Quieter production lines. I ran out of space on mod list so this and next one are optional. Add after mod #34. \ 107... Quieter Settlements PS4 - Wasteland Workshop - Quieter fusion generators. Add after mod #34. \ 108... [PS4] Simple Settlers (Immortal Edition) - Instead of #33, so generic settlers don't die during settlement attacks. \ 109... Reduced Rubble Etc. - Safely reduces density of unimportant objects by 50-75%. Add after #44 or swap with #45. \ 110... Vrexia's Magical Rings - Add after #57 only if you get poison/perception bug where your PER is shown as (-1). You can offset it by equiping multiple rings from this mod (created at chem bench). Didnt found a better way yet. \ 111... Pip-Boy Flashlight (Brighter) - For a smaller, brighter flashlight swap #96 with #95 and replace #95 with this.

Remove, if you want:

Stock, ugly Pip-Boy color - #3 \ No tinkering with legendary effects - #5 \ No powerful groups wandering and attacking places - #15 \ Radstags to be less agressive - #17 \ Dont care about building - #20 #21 #22 \ Dont care about decorating settlements - #24 #25 \ Annoying wandering brahmins instead of dogs - #31 \ Cash register sounds when gaining exp - #39 \ Old vanilla dusk and dawn lighting - #49 \ Don't use VATS much - #53 #54 #55 \ Prefer old combat scopes - #64 #65 #66 \ Don't want uncover map perk and will never unlock it - #84 \ Don't have any weapon skins from Creation Club - #90 \ Faster leveling - #92 \ To gain building EXP - #94 \ Start with 7 extra SPECIAL points to distribute - #97 \ Loot and enemies respawn after time - #98 \ Fast travel to take time - #99 \ Days be vanilla length - #100

Known issues, bugs, glitches, exploits:

Some of those are present in vanilla game. I just mention every problem encountered during testing and not fully fixed. - Ground textures in and around sanctuary flicker black. FIX: Fixes itself. Possibly after short time or reload. - Creature cages cost too much in building menu. NO FIX: Did not found a safe and balanced fix yet, so cages are most likely out of reach, because cost is absurd. - Green chest containing flare gun and 10k flares after exiting vault 111. FIX: Mod dev forgot to delete it. Ignore it or if it bothers you much, remove mod #83, which I don't recommend doing. - Hubby secret basement in Sanctuary. NO FIX: Its up to you if you want to use its content. Just easier difficulty option, but not game breaking. - Hacking rank 4 seems useless or has wrong description. NO FIX: Needs proper check. - Wall turrets sometimes glitches and play sound on repeat. FIX: Re-enter the area or reload save. - Contact frag mines seems to have too low damage. FIX: Just dont craft them. Rest of new explosives should work fine even that it shows low damage values in description. - Perception low, constant (-1) PER in stats because of poison damage/resistance bug. FIX: Add mod #110 and equip perception rings. Dont delete the mod. Cant find safer solution for now. Rings dont take equipment slots. - Action girl perk have only one rank on female character and two on male. NO FIX: Just 25% AP regen loss at high level. Not a big deal. - Bubblegum seems to unintentionally quench thirst a bit and kind vendors give it for free. NO FIX: Free candies. Its better to use them to slow down time. - Incorrect cost to build concrete foundations. FIX: Use mod #20 to add tons of foundations in newly added category Structures-Concrete. - OCDecorator replaces creation club menu. FIX: Items from CC are still available in other building categories. Ignore or delete mod #24 + #25 if you dont care about its function. - Few perk descriptions might be slightly incorrect or missing. NO FIX: Nothing important to worry about. - Three street lights, powered water pump, industrial purifier and subway light have incorrect build costs. NO FIX: These have wrong values, but items like clean sofa or tv are more expensive to build on purpose though. - Pip-boy light wont transfer from first to third person camera view. FIX: Turn flashlight off and on. - Water surface sometimes flash black when moving underwater. NO FIX: Its not very noticable and you don't dive much in FO4 anyway. - Can't use Wattz Consumer Electronics terminal, animation stops. FIX: There is a radroach behind the wall. Kill it by swinging melee, explosives or reenter area. - Flashlight in Vault111 has incorrect beam look/color. FIX: It will fix itself after mods load right after you leave Vault111, dont worry.

v1.00 - Initial version.

Have fun!

The greatest financial risk for physicians is losing the ability to turn the knowledge and skills you spent a decade learning into a huge pile of money by working in your profession for decades. There are risks that could show up in your life that would prevent you from being able to accomplish this task. One of the most common of these risks is an extended or even permanent disability. Insurance companies estimate that as many as one in seven doctors will be disabled at some point during their career. While many imagine this will occur in a sudden traumatic accident, medical illness is actually a more common cause of disability that prevents a doctor from working. Physician disability is a complicated type of insurance. This post will give you the “must-know” information to secure the best protection and help you avoid common disability insurance mistakes.

TL;DR: Key Takeaways: What Doctors Need to Know About Disability Insurance

1. The best Disability Insurance policy is an individual, portable, own-occupation, specialty-specific policy.
2. Purchase disability insurance from an independent agent who can show you policies from all of the major companies. We have a list of recommended Disability Insurance agents used by thousands of white coat investors each year.
3. Buy as much disability insurance as they are willing to sell you as a resident. Include a future purchase option (sometimes called a “benefit purchase rider” or “future increase option”) and a cost of living disability insurance rider.
4. As an attending, increase your coverage to cover both your living expenses and retirement savings if you were to work to age 65.
5. You may get sticker shock, but the reason disability insurance is expensive is that it actually gets used. Slightly more than 1 out of 4 adults will experience a disability before they retire. Physician disability insurance agents often use a figure of 1 out of 7 doctors actually using the disability insurance they purchase. Whatever the true statistic may be, it's certainly high enough to insure against.

Do not take the risk of not having disability insurance.

What Is Disability Insurance?

Disability insurance gives you an income to live on if you become so disabled that you can no longer work.
If you become disabled, a long-term disability insurance policy pays a predetermined amount each month until you either recover from your disability or reach age 65-67. (Note: Policies vary. It is possible to buy a policy that pays to age 70 or even, for a very high premium, until death).

Why Do Physicians Need Disability Insurance?

One out of seven doctors end up having to use their disability insurance. Losing the ability to turn the knowledge and skills you spent a decade learning into a pile of money by working in your profession for decades is one of the most expensive risks that physicians face. Your most valuable asset is your ability to work.

How Does Disability Insurance Work?

Disability insurance is a pretty straightforward proposition. You buy a policy and pay your premium monthly or annually. If you become disabled, you (and your doctor) fill out the paperwork to prove it to the satisfaction of the insurance company and then they pay you the promised monthly benefit until you either recover from your disability or the insurance company meets its contractual obligation to pay the benefit.

Short-Term vs. Long-Term Disability

Disability insurance is most commonly divided into short-term and long-term.

Short-Term Disability

A short-term disability policy generally begins paying just as soon as you get disabled and then pays for a maximum period of 3-24 months. These policies are often provided by an employer as an employee benefit. Short-term disability, while inconvenient financially, is not generally a financial catastrophe for a physician saving for retirement with an emergency fund. As a result, many doctors do not buy short-term disability policies at all.

Long-Term Disability

A long-term disability policy generally does not pay immediately, but only begins to pay after a waiting period ranging from 1-24 months (typically 3 months). Then, the policy will continue to pay you a benefit each month until age 65, 67, or 70, depending on the policy. Note that a 3 month waiting period typically means your first check won't come until the end of the first month after the 3 months, so it's really a 4 month waiting period. Since losing your ability to earn a living for the rest of your life is a financial catastrophe, any doctor who is not financially independent should buy a long-term disability insurance policy.

What Does Disability Insurance Cover?

Disability insurance covers all kinds of disabilities. The best (and unfortunately most expensive) policies cover the widest range of potential disabilities.

The Definition of Disability

The most important feature is the definition of disability. Disability insurance differs from life insurance in numerous ways, but none is more significant than in defining exactly when you become disabled (and when you become enabled again). The broader the definition of disability you get in your policy, the more the policy will cost.
Unlike life insurance, where life and death are pretty black and white, disability has 50 shades of gray. You want a policy with a strong, broad definition of disability that will cover any possible type of disability? That means “true own-occupation, specialty-specific” and no limitations on things such as psychiatric conditions or addictions. This is the main difference between the “Big 5” companies and others. Even among the “Big 5,” there are slight differences. It is OK not to purchase the policy with the very best definition of disability, but the weaker the definition, the bigger the discount you should expect.

Own-Occupation, Specialty-Specific

Probably the most important aspect of the definition for doctors is that it be specific to your occupation. For instance, if I lost my left thumb, there are a number of procedures in emergency medicine that I could no longer do. I would be completely disabled from managing a busy emergency department by myself. But I could probably still go do urgent care work. A specialty-specific definition of disability in my policy would provide me with my full disability payments in addition to the money I make at the urgent care. Sometimes, the “specialty-specific” clause is inherent to the policy, and at other times it is an additional rider (a piece of paper added to the policy for which you pay an additional premium). Either way, you almost surely want to get this in your policy. Here are the various definitions, starting with own occupation and progressing to any occupation.

Own-Occupation Definition

Under this definition, your policy will pay if you cannot work in your occupation/specialty, even if you can and do work in another field and make as much money as you want.
Own-occupation policies cover people based on the occupational duties they are performing at the time of claim. If your policy includes an own-occupation definition of total disability and you are exclusively performing the customary duties of your medical specialty or sub-specialty at the time of the claim, the policy will cover you when unable to perform your specialty or sub-specialty. If you have transitioned into a different role or expanded into a new career path that requires much less direct patient contact or procedural duties, you may no longer be considered totally disabled when unable to work in your specialty or sub-specialty. This is because your “occupation(s)” involves additional material and substantial duties, no longer limited to the performance of your medical specialty or sub-specialty. In these instances, you may be considered partially disabled or not disabled at all, depending on the exact circumstances.

Transitional Own-Occupation

Your policy will pay if you cannot work in your occupation/specialty, even if you can and do work in another field. But if you exceed your previous income while you now work in another field, your monthly benefit from the policy would likely be lowered.

Modified Own-Occupation

Your policy will only pay if you can't work in your occupation/specialty AND if you are not working in another field. This definition is also sometimes called “Own-Occupation, Not Engaged” or “Own-Occupation, Not Working.”

Any-Occupation

Your policy will only pay if you cannot work in any occupation based on education, training or experience. Note that some policies are own-occupation for a couple of years and then transition to any-occupation.
One company out there (Northwestern Mutual) sells a policy with a definition that they claim is BETTER than own-occupation. They call it Medical Own-Occupation, but in reality, it is just a form of modified own-occupation. Learn more about the NML Medical Own-Occupation Definition.

Do You Really Need an Own-Occupation, Specialty-Specific Policy?

Some non-procedural physicians argue that they might not need a true own-occupation policy. They reason that if they are so disabled that they cannot practice their specialty, they probably cannot do anything else. So, they accept a less broad definition of disability to save some dollars on the premium. If you choose to do this, make sure you understand the exact circumstances under which your policy will and will not pay out.

Mental Disorders/Substance Abuse

Many policies will only cover mental illness or substance abuse-related disabilities for a period of two years. I know an attorney who couldn't practice law after developing bipolar syndrome in his 30s. It took over a decade to get it under control. He had a policy that covered mental illness indefinitely, which prevented financial catastrophe from striking him and his family.
According to the April 2011 issue of Current Psychiatry Magazine, physicians are not immune to depression and have an increased risk of suicide. Additionally, the lack of distinction between a psychiatric diagnosis and impairment stigmatizes physicians and impedes treatment.
You'll need to decide whether this is a risk you're willing to run. If you want mental illness covered like every other illness, you'll be paying more.

Presumptive Total Disability

As you well know, disability can be defined in many shades of gray. In the event of your disability, you can expect a paperwork fight between you, your physician, the disability insurance company, and maybe even your attorney. However, most policies contain a section that defines “presumptive total disability” where you can be assured there won't be much arguing from the insurance company. Even better, the waiting period will be waived and you'll start getting payments right away.
Anything short of that, and you're going to have to get your doctor to certify your disability and get the insurance company to accept it. At times, this can involve visits to multiple specialists and even hiring an attorney. Note that with some companies, presumptive disability does not need to be permanent.

Cosmetic Surgery/Transplant Surgery

Some policies will cover you if your disability is the result of cosmetic surgery or the result of donating a kidney or other body part to someone else. Others will not. Best to read your policy carefully and know what it does and does not cover.

Disability Insurance Exclusions & Limitations

Disability insurance policies generally exclude any medical conditions you have at the time of applying for insurance. For example, if you already have chronic back pain, the policy will not provide a benefit if you are disabled due to a back condition. In addition, if you admit to participating in dangerous activities such as scuba diving, rock climbing, flying, and sky-diving, the policy will likely be issued with a rider that excludes those activities from coverage. Other exclusions may also apply, such as acts of war, normal pregnancy, and foreign travel. Here is a list of common exclusions:

• War or Act of War (this could probably be interpreted pretty broadly)
• Active Military Duty (having served, this is pretty stupid since 95%+ of our military folks are never in any kind of serious danger of being hurt by a combatant)
• Normal Pregnancy (don't want to work because you're eight months pregnant? Don't bother trying to get disability benefits for that)
• Foreign Travel (varies by policy, but many don't cover you during that European vacation, much less that humanitarian trip to Sudan—read the fine print)
• Mental/Nervous Disorder (many companies limit benefits to two years, where they might pay for “physical” disorders until you're 65 years old)
• Medical Exclusions (any medical conditions you have at the time the policy is issued will likely be excluded, meaning if you have heart disease at the time of issuance and it leads to you being disabled five years later, the policy isn't going to pay. Again, apply when you are young and healthy and/or when you haven't had medical problems for several years to minimize this.)

Residual Disability

Residual disability refers to being only partially disabled. This may occur from the initial injury or illness or be part of the process of recovery. You generally need to buy an additional rider to cover this. Read this rider carefully, it can be a bit complicated.
Imagine developing painful lumbar radiculopathy that keeps you from working more than 20 hours a week. This is the part of your policy that will cover that. This rider will also explain how much you get if you are partially disabled. My old policy says it pays the whole benefit (total disability) if I can't earn at least 20% of my “indexed prior monthly earnings,” which is basically the money I earn at my job. It doesn't count my investments, other disability income policies, rent from a rental property, or my nonvocational activities. It doesn't pay anything if my earnings aren't reduced at least 20%. If I am making between 20%-80% of what I made previously, I get the total disability benefit times the ratio of my loss of income for that month divided by my indexed prior monthly earnings. Note that with some companies, the partial disability rider will kick in at 15%.
Some contracts use “or” in the contract and others use “and” in the contracxt. For instance, a stronger policy would trigger the partial disability rider if you had a loss of income or a loss of time or a loss of duty whereas a weaker contract would require loss of income and loss of time and loss of duty where all of those triggers must be met.

Partial Disability vs. Residual Disability

Partial disability and residual disability are generally considered to be the same thing, but there is a technical difference at some companies. For example, at one company, a partial disability rider requires total disability during the elimination period and the residual disability rider does not. With another company, partial refers to the disability, such as one that only affects one part of the body (such as one arm), while residual refers to a decrease in earnings. Either way, the key is to understand how the residual/partial rider works in the policy you actually purchase.

Recovery Benefits

A physician should consider a contract that will continuing paying them a portion of their benefits upon recovery from a disability if their income continues to be down at least 15%-20%. Most carriers will pay a recovery benefit for the benefit period although one only pays for 12 months. This is especially important for practice owners. Think if a dentist were to be disabled for 6 months and then recovers and goes back to their practice. Many of their patients may have gone elsewhere because the dentist sees his patients twice a year. It could take several years to get back to where he/she was at before becoming disabled.

Recommendations for Physicians on Disability Insurance Riders

Here's an easy cheat card to help you know at a glance what we think about all of the various riders available.
https://preview.redd.it/akf6t5iqfn0d1.png?width=800&format=png&auto=webp&s=3f8b415d0101d729fdfa51bc9147993309147d75

Who Needs Disability Insurance?

Nearly every high-income professional in their first decade or two out of school should own a policy. Your most valuable asset is your ability to work. So, if you do not own a disability insurance policy, you need to go get one, now. If you have an income, it's time to buy a policy, even if money is tight as a resident. The only exception is if you do not rely on your income to live. If you are already financially independent, it's OK not to buy disability insurance. However, even if you are frugal and married to another high earner, you may wish to still have a policy. You could both become disabled, or you could become divorced.

How Much Physician Disability Insurance Do I Need?

As a resident, you typically cannot afford to buy as much as you need, but you should be able to do so even as a brand-new attending. Basically, you need to buy enough disability insurance to cover both your living expenses and your retirement savings if you were to work to age 65 but not your taxes. Physician disability insurance payouts are generally tax-free since they are usually paid with post-tax dollars.
Note that how much you need has little to do with your income and everything to do with what you spend. The less you spend, the less insurance you need to buy. Insurance agents would love to sell you the largest possible policy (which usually works out to be about 2/3 of your gross income, but it is possible to combine two companies to get even more), so you'll need to decide how much you need on your own. Resident physicians typically buy a $5,000 per month benefit and attending physicians typically buy a benefit in the $10,000-$15,000 per month range, but there are plenty of docs who buy both more and less. If your plan in the event of disability is to rely on the income of your spouse, you may not need disability insurance at all.

Average Cost of Disability Insurance for Physicians

Unlike cheaper insurance policies like term life and umbrella policies, physician disability insurance is expensive, although not quite as expensive as your malpractice insurance. The reason it costs so much is it actually gets used. The likelihood of you acquiring a long-term disability during your working years is approximately seven times as high as your risk of dying in those years. A typical policy bought on a healthy doc in their 20s or 30s will cost something between 2%-6% of the benefit. If your monthly benefit is $10,000, expect to spend $200-$600 per month for that. Perhaps the sticker shock you get upon being quoted prices will motivate you to reach financial independence as soon as possible so you can cancel the policy.

Graded vs. Level Premiums

One way to save money on your policy is to get graded premiums. Not all policies offer this feature, but those that do will charge you less in the first few years and more in later years. Level premium policies charge you the same amount in premium every year. A graded premium policy accounts for the fact that you become more likely to become disabled as you go through life. However, it can be very beneficial to you because your need for insurance actually falls continually throughout your career as your build your retirement nest egg.
Once you become financially independent, you can drop the insurance completely. This is a good idea since the total benefits a policy could potentially pay are also dropping throughout your life (since the policy will generally only pay until you are in your mid- to late-60s). Many white coat investors who are great savers hit financial independence by mid-career. If you are one of those, you are likely to come out ahead using graded premiums instead of level premiums.

What Disability Insurance Discounts Are Available for Doctors?

Like other types of insurance, disability insurance is sold by agents who are paid commissions by the insurance companies to sell their products. It is a very competitive business. The insurance companies want agents, especially the independent agents you should be buying from, to preferentially sell their products. To incentivize the agents, they offer discounts that are only available through certain agents. Experienced, high-volume agents can often provide you with the same policy at a cheaper rate than a newer, lower-volume agent. Thus, it pays to use an experienced agent and shop around with two or three of them. Nearly every doctor should qualify for some type of discount on their policy—10%-30% premium discounts are not unusual. Types of discounts include:

• Unisex discounts
• Student/Resident/Fellow discounts
• Multi-life institution discounts
• Guaranteed Standard Issue (GSI) institution discounts
• Association discounts

Learn more about physician disability insurance discounts.

How Do I Buy Disability Insurance?

The key to physician disability insurance is the independent agent. The agent is going to be paid a great commission by the insurance company no matter which policy you choose. Assuming policies with similar benefits, the commission isn't going to be all that different. Plus, these agents get plenty of business and none of them are starving, so they have little incentive to sell you an inferior policy for a slightly higher commission. Their reputation is worth far more than a few extra dollars in commission. Since you are (indirectly) paying the agent a very nice commission, don't feel bad about using their time and expertise to fully understand this complicated product.
For most doctors, this is a purchase that is only done once or twice in their life. Have the agent quote you different physician disability policies from each of the “Big 5” companies and show you the strengths and weaknesses of each. If you have a policy from work or your professional association, bring it in with you and have it included in the comparison. Then, you can know you made an educated decision and you can buy it and forget about it. Also, be sure to ask for a discount. The vast majority of doctors will qualify for a 5%-30% association or employer-related discount, and a top-notch agent will help you get that.

What Type of Disability Insurance Should I Buy?

There are two main types of disability policies: individual policies and group policies. As a general rule, individual policies have stronger definitions of disability. Many group policies are not own-occupation policies. Individual policies are also portable, in that you can change jobs and take them with you.

Individual Disability Policy

There are a number of benefits of an individual policy. The main one is that you are in control of all the details. You get to choose how much insurance you want to pay for. You get to choose which of the bells and whistles you are going to pay for. The policy is also “portable,” meaning you still have it if you change employers (or if your employer just decides to change the policy). As a general rule, the policy is also “stronger,” meaning it is more likely to actually pay you if you get disabled.

Group Disability Policy

A group policy provided by your employer is usually not portable, although sometimes you are allowed to take over the entire premium and take it with you. Group policies also frequently have premiums that increase every year or every five years, whereas an individual policy usually has level premiums. Group policies paid for by your employer may also pay a taxable benefit, rather than the tax-free benefit provided by an individual policy. Aside from the lower cost, the main benefit of a group policy is that it may be easier to qualify for. It may not require any sort of medical exam or blood work, and it may not ask any pesky questions about your medical conditions and dangerous hobbies such as rock climbing, skydiving, scuba diving, or flying.

How to Compare Disability Insurance Policies

The most important feature is the definition of disability. You want a policy with a strong, broad definition of disability that will cover any possible type of disability. That usually means “own-occupation, specialty-specific” and no limitations on things such as psychiatric conditions or addictions. This is the main difference between the “Big 5” companies and others.
Since disability is complicated, disability insurance policies are complicated. There are dozens of differences from one policy to another, making them difficult to compare. Use your independent agent for recommendations on what matters most. Just for an example, take a look at this chart of all the differences you could see between one policy and another.

When to Buy Disability Insurance?

You should buy disability insurance just before you become disabled. Since you don't know when that time could be, earlier is generally better. However, disability insurance is also expensive, and when you are young and poor, you have lots of other great uses for your money. A good compromise is to buy a small policy as you enter residency and then upgrade to a more robust disability insurance plan just before leaving residency. The younger you are, the healthier you are, and the fewer dangerous hobbies you engage in, the cheaper your premiums will be for the same benefit.

Best Disability Insurance for Physicians

I keep a list of those I consider the best disability insurance agents in the country. Save yourself the work of finding a good one you can trust and use the same agents that have been used by thousands of WCI readers in the past. You do not need someone local that you can sit down across the table from. It is better to have someone who has sold policies to hundreds of docs this year working with you by phone, Skype, Zoom, and email than someone you can sit down with who has only sold four policies. In addition, if there is some issue with one of these agents, I can usually help you resolve it quickly.
Information in this space rapidly changes. While we try to keep The White Coat Investor website as up-to-date as possible, our recommended agents are going to be our best source for updated information. I cannot emphasize how strongly I suggest you use them, whether buying your first policy or simply reviewing what you already have.