Denial for Failure to be Under the regular and appropriate care of a Physician

If this term appears as part of the definition of what it means to be totally disabled under your contract, then this can have potentially unexpected results. For example, if you are unable to work because of a psychiatric illness that has not responded to treatment and you, logically, are no longer in treatment, your insurer, while agreeing that you are incapable of work, can decide to stop paying your benefit due to your failure to be under the regular and appropriate care of a physician. This means that even if you follow your doctor’s advice and stop attending ineffective treatment, your insurer may stop paying your benefits and point out that under the wording of your contract, you are not “disabled” because you are not under the regular and appropriate care of a physician. This can be particularly difficult and unfair to people who are disabled due to drug or alcohol dependency as denial and relapse are hallmarks of these illnesses.

If this term shows up somewhere other than as part of the definition of disability, then the insurer can raise it as a reason to deny benefits in circumstances where someone is not seeing their doctor regularly or following a recommended course of treatment. However, there may be sound reasons for you not following a course of treatment. Whether a refusal of treatment is reasonable is a question that depends on all of the circumstances unique to your case. For example, your own doctor may be in agreement with your decision to refuse treatment; or you have decided to follow another of several appropriate treatments; or the risks of the recommended treatment outweigh the benefits; or access to treatment is limited because you live in a remote area; etc.

Once again, just because the insurance company tells you that your claim is denied due to your failure to be under the “regular” and “appropriate” care of a physician doesn’t mean that your insurer’s analysis is correct or conforms to legal or medical realities. If you have been denied benefits on the basis of your supposed failure to be “under the regular and appropriate care of a physician, remember there may be another way of looking at these terms. The sooner you put the facts before experienced counsel, the sooner you will understand your options.

Most disability policies contain a provision requiring you to be under the “regular” (or “continuous”) and “appropriate” care of a physician.  A denial based on your failure to comply with this requirement can be frustrating given that these terms are often ill-defined, confusing and open to interpretation depending on where this term actually appears in your contract.

If this term appears as part of the definition of what it means to be totally disabled under your contract, then this can have potentially unexpected results. For example, if you are unable to work because of a psychiatric illness that has not responded to treatment and you, logically, are no longer in treatment, your insurer, while agreeing that you are incapable of work, can decide to stop paying your benefit due to your failure to be under the regular and appropriate care of a physician. This means that even if you follow your doctor’s advice and stop attending ineffective treatment, your insurer may stop paying your benefits and point out that under the wording of your contract, you are not “disabled” because you are not under the regular and appropriate care of a physician. This can be particularly difficult and unfair to people who are disabled due to drug or alcohol dependency as denial and relapse are hallmarks of these illnesses.

If this term shows up somewhere other than as part of the definition of disability, then the insurer can raise it as a reason to deny benefits in circumstances where someone is not seeing their doctor regularly or following a recommended course of treatment. However, there may be sound reasons for you not following a course of treatment. Whether a refusal of treatment is reasonable is a question that depends on all of the circumstances unique to your case. For example, your own doctor may be in agreement with your decision to refuse treatment; or you have decided to follow another of several appropriate treatments; or the risks of the recommended treatment outweigh the benefits; or access to treatment is limited because you live in a remote area; etc.

Once again, just because the insurance company tells you that your claim is denied due to your failure to be under the “regular” and “appropriate” care of a physician doesn’t mean that your insurer’s analysis is correct or conforms to legal or medical realities. If you have been denied benefits on the basis of your supposed failure to be “under the regular and appropriate care of a physician, remember there may be another way of looking at these terms. The sooner you put the facts before experienced counsel, the sooner you will understand your options.