Does Insurers Dictate Medical Care?

Are insurance companies dictating your medical care?

Disability insurance provides a crucial safety net that can protect your ability to earn an income in the event of a serious illness or injury. However, not all policies are created equal, and in some rare cases an insurance company may deny disability benefits based on a claimant’s method of recovery.

For instance, if your injury requires you to undergo a certain surgery in order for you to return to work, and you refuse the operation, depending on your policy, your insurance company may have the right to withhold your benefits.

Many people are taken by surprise by these provisions when it comes time to file a claim and are surprised and dismayed thinking  insurance companies dictating medical care is a privacy problem. So to avoid confusion, here’s a look at the two most common insurance policy provisions regarding medical care:

Regular Care

Typically found in older disability insurance policies, ‘Regular Care’ provisions simply require the claimant to seek the “regular care and attendance” of a physician. This means that under this type of policy, the insurance company cannot require you to undergo any prescribed procedure or treatment plan, even if such a procedure might successfully treat your injury and allow you to return to work sooner. Because they essentially only require that the insured visits a physician to determine whether or not his or her disability persists, Regular Care policies are becoming less frequent.

Appropriate Care

Whereas Regular Care policies leave treatment almost entirely in the hands of the insured, ‘Appropriate Care’ policies make certain provisions regarding the type of care required to meet the terms of the policy.

Requiring that claimants undergo a treatment plan that is “appropriate for the condition causing the disability,” this type of policy will require the insured to not only receive regular medical care, but to seek and undergo care that is suitable for their specific illness or injury.

This usually simply translates to seeing a specialist, or specialists whose work focuses on the nature of your particular condition, rather than simply visiting your general practitioner. However, in some rare cases the insured might be required to undergo doctor-recommended surgeries or other procedures in order to receive benefits.

While on the surface it may sound like these provisions constitute an attempt by your insurance provider to dictate the terms of your recovery, in most cases, these provisions make little difference in the lives of the insured because most people will naturally seek the most appropriate and effective treatment options available so they can get back to normal life as soon as possible. Still, if you are concerned about such a provision in your policy, talk to your insurance provider and see what options might be available to you.

Is it Legal?

Since we are a litigious society, there are cases where the insured (claimant) has brought an action against the insurance carrier:

Slate v. Mass Mutual Life Insurance Co. 2015 In this case the court found that policy language created only a “minimal duty” to provide evidence of ongoing care.

The claimant failed to fulfill this minimal duty by not having medical care for long gaps in time (4 visits in 8 years) in treatment.

In Sager v. Standard Insurance Co in 2011, the court stated: “Of course, the physician’s care requirement does not permit the insurer to determine the insured’s course of treatment.

The bottom line here is that your disability insurer has little interest in your private medical care but rather, they do have an interest in determining that an insured is actually disabled and is taking the necessary steps to obtain the medical treatment that might help them with recovery and thus returning to work.

Get Expert Advice about Your Duties after the Claim

When shopping for a disability plan the is right for you, it’s imperative that you speak with an experienced and reputable agent at LifeInsure who can help you navigate the terms and conditions of your policy so you will know what you can expect if and when you file a disability claim with your disability insurance provider. As they say, “the devil is in the details” so it’s incumbant on the applicant to know and understand the details regarding the claim process for the insurer you select for coverage.

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