{4:00 minutes to read} Most long-term disability policies have provisions which specify that you must be receiving appropriate care and treatment to receive your disability benefits.
Long-term disability policies establish this concept through policy language, defining “disability” in a number of ways. For example,
1. Some policies define disability as being unable to perform the material and substantial duties of your regular occupation, and being in the care of a physician.
2. Other policies define disability as being unable to perform the duties of your occupation. Then, in the exclusions portion of the agreement, the policy will specify that they will not pay any benefits during any time period that you are not receiving care prescribed by a physician which is appropriate for your disability.
What’s the difference?
In the first example (above), you may not even be considered disabled because you have not met the criteria under the policy’s definition of the word “disability,” if you are not under the care of a physician.
Under the provisions of a policy as shown in the second example, you may be considered disabled, but with no payable benefits because you are not receiving “appropriate care.”
“Regular care” of a physician generally means you receive regular and continuous treatment based on the nature of the disabling condition and your progress.
The distinction between the two becomes an issue in cases where the medical reason for your disability is not easily determined.
For example, a policyholder is having cognitive problems and feeling fatigued. He makes appointments with both a psychologist and a neurologist, and neither can find the problem. He is unable to work. He schedules an appointment with an oncologist to determine if he has cancer — he learns he does not have cancer. Months later they run an HIV test, and he discovers that he is HIV positive and begins treatment. In a case like this, the insurance company may argue that he was not receiving care and treatment appropriate for his condition.
How the policy defines “disability” also becomes important when someone has a psychiatric condition. One of the hallmarks of paranoid schizophrenia, for example, is noncompliance with medications. Insurance companies have argued and some courts have ruled that the policyholder is not entitled to benefits under the policy because the insured went off his medication.
What happens when you believe that the treatment itself might be harmful? Let’s say you have a back condition and your doctor recommends physical therapy, but the treatments are really painful and you believe they are causing greater damage. You stop going to physical therapy and the insurance company says that you’re not getting treatment and care appropriate for your condition and they discontinue your benefits.
There is plenty of good case law to establish: If the cure comes with a reasonable probability of additional injury, you do not have to comply.
Other typical examples include that an insured person is not required to undergo surgery or take medication(s) with harmful side effects in order to receive benefits.
How will you determine whether refusing to undergo certain medical treatments will jeopardize your benefits?
Evan S. Schwartz
Founder of Schwartz, Conroy & Hack
800-745-1755
ESS@schwartzlawpc.com