Has the insurance company denied disability benefits by controlling your terms of care and medical treatment?
Disability insurance policies contain provisions which, if not followed, the claims adjuster can use to deny coverage. These provisions establish whether you are satisfying the care provisions in your policy.
Controlling your terms of medical care in a way not stated in the disability insurance policy can be a tactic by the insurer to avoid paying disability benefits.
Under Regular Care
For example, most doctors’ and dentists’ disability policies require you to be under the “regular care” of a physician that is appropriate for the disabling condition. Wording may vary: policies might state “under the care of a physician other than yourself,” or “under the care and attendance of a physician” or similar.
Policies often do not clearly define “regular care” and this can be the point of dispute in a disability claim. A policy may also not clearly define “doctor” or “physician.”
Under Appropriate Care – Appropriate Medical Treatment
A more important stipulation in physician’s disability claims is the matter of receiving “appropriate care” as a provision of the policy.
This may be defined in wording such as: “undergoing ongoing medical treatment and care of the disability that conforms to generally accepted medical standards, including frequency of treatment and care.”
When you are on claim, an award of disability benefits is dependent upon you receiving “appropriate care” or “appropriate medical treatment.” This is true of most physicians’ disability insurance policies.
This provision has its purpose. Appropriate medical treatment under the regular care of a physician provides valuable evidentiary medical records. Also, such treatment contributes to improvement of many impairments.
Still, most “appropriate care” provisions are vague, and therefore the source of many claim denials. Some insurance companies aggressively exploit this to try to regulate the terms of care and the level of medical treatment provided to you.
Controlling your terms of care by compelling you to seek corrective surgery or other treatment.
This includes requiring you to seek medical treatment with the specific objective of returning to work in your “own occupation.” It may also mean telling you to undergo curative surgery in order to remain eligible for disability payments.
For example, your treating doctor, an orthopedic surgeon, is treating your spinal cord disorder with medication and physical therapy. Your insurance company insists that you submit to spinal surgery as a condition to being approved for monthly disability payments.
The insurer claims that other treatments have failed, and that this surgery is low-risk with a high success rate. They argue that your refusal would be unreasonable and would be grounds for denial.
You disagree with the insurance company’s departure from the policy terms. The appropriate medical treatment provision in your policy says that, to receive benefits, you must receive regular and ongoing care by a doctor or physician that is appropriate for the disabling condition. There is no language obliging you to submit to surgery, and your current physician is an expert in treating your disabling condition.
You do not want to face the risks of surgery. You wish to refuse. What should you do?
Insurers cannot dictate what they think should be the “standard of care” as being the appropriate medical treatment. Unless required per the policy, insurers have no right to stipulate additional treatment as a condition for disability payments, or as a condition of partial disability.
By controlling your terms of care, the insurer controls your claim.
The appropriate care/appropriate medical treatment provision in a policy should not be misconstrued as a way to defeat otherwise deserving claims.
Likewise, if a doctor or dentist becomes disabled while covered under a disability insurance policy, he or she should not lose their benefit payments if they choose not to pursue unnecessary medical treatment.
If your disability insurance company is controlling your terms of care as a tactic to avoid paying disability benefits, you should contact a doctor disability insurance lawyer without delay.