Every disability insurance policy includes a requirement that the insured must be under the care of a primary physician as a condition of receiving or continuing to receive benefits. But what does it mean to be under the care of a physician? The question is more complex than it seems at first glance.

When Does One Have to Be Under the Care of a Physician?

While insurance companies often contend that a disability cannot be recognized until the date the insured first sees a doctor for their condition, many courts have rejected that assertion. Instead, courts have found that disability benefit claimants only need to be under the care of a doctor when they submit their claim. Rulings such as Berg v. New York Life Insurance Company, a case we litigated, found the meaning of the “care of a physician” requirement subject to multiple interpretations. The court overruled the insurance company’s argument that a disability does not exist until the day the insured first sees a doctor, finding such a reading absurd. The court illustrated its point by observing: “Hypochondriacs might find a doctor who spots an illness at the earliest possible moment, while those who lack the resources to see doctors regularly might suffer for months or years and yet not be considered to have an illness or injury.” Accordingly, the court found it makes “no sense to impose a requirement that a physician visit determines the time when a disability commenced.”

Learn About Berg v. New York Life Insurance Company Case

A disability may thus be found to have started well before the claimant first consulted a doctor for the disabling condition so long as a doctor, once consulted, can relate the disability start date back to an earlier date. Since most disabling illnesses do not have a definable start date, and even many injuries do not become disabilities until some time after the date of the initial injury, this is a sensible approach to the question of when does one have to be under the care of a doctor.

How Long Is a Doctor’s Care Necessary?

No disability benefit claim will be approved without a certification from a treating doctor that there is a diagnosable condition requiring medical attention. However, some conditions plateau after a period of time; and no amount of additional treatment will cause a remission of the impairment. As a result, the care of a physician requirement in a disability insurance policy is relaxed when it is certain that no improvement is expected and there would be no point in seeing a doctor or in seeing a doctor more frequently than the schedule a doctor sets. Obviously, no one would stop seeing a doctor if their condition is worsening or if they are experiencing severe pain or discomfort. But when no purpose would be served by seeing a doctor more than once a year, a disability insurance company cannot insist on more frequent treatment.

Does the Care of a Physician Requirement Allow the Insurance Company to Direct the Course of Treatment?

Many disability insurance policies include clauses that state the insured must receive “appropriate care” for their condition. While such clauses give insurers a certain amount of leeway to require the insured to receive care from a doctor appropriate to their condition, that does not give insurance companies carte blanche to influence the course of treatment. An example is a case where an insurance company rejected a claim because it believed the claimant should be seeing a rheumatologist (Federal appellate panel addresses insureds disability insurance policy). Because the plaintiff introduced evidence from her internist that the care she was receiving would not be any different than the care a rheumatologist would provide, the insurance company’s argument was rejected. However, claimants who have conditions that can only be treated by a specialist may not choose to unilaterally reject such treatment if there is an appropriate care clause in the insurance policy.

If, however, the insurance company demands that the insurer undergo highly invasive treatment as a condition of receiving benefits, most courts have held the insured need not undergo such treatment unless there is a high degree of likelihood that the treatment will be successful and a very low risk of complications or adverse side effects (Who decides whether treatment is appropriate?). An example is carpal tunnel surgery. While some courts have ruled that a claimant cannot be compelled to undergo such surgery, other courts have found the refusal to undergo the treatment grounds for benefits to be denied.

The Social Security Administration has a regulation on this issue that applies to the Social Security disability program. While the regulation (20 C.F.R. § 404.1560) states that claimants are required to follow prescribed treatment if the treatment is expected to restore a claimant’s ability to work, the regulation lists exceptions:

  1. The specific medical treatment is contrary to the established teaching and tenets of your religion;
  2. The prescribed treatment would be cataract surgery for one eye, when there is an impairment of the other eye resulting in a severe loss of vision and is not subject to improvement through treatment;
  3. Surgery was previously performed with unsuccessful results and the same surgery is again being recommended for the same impairment;
  4. The treatment because of its magnitude (e.g., open-heart surgery), unusual nature (e.g., organ transplant), or other reason is very risky for you; or
  5. The treatment involves amputation of an extremity or a major part of an extremity.

This issue becomes even more complex where there is no consensus in the medical community on the standard of care for a condition, with respect to mind-altering psychotropic medication or medications that have addictive properties, or even medications that cause sedation or other side effects that can be bothersome.

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Concluding Thoughts

There are many complexities to the issue of the care of a physician clause in a disability insurance policy, but almost all of the issues can be resolved with the application of simple common sense. Insurance companies have every right to guard against fraud by insisting that disability benefit claimants be under a doctor’s care. It is equally obvious, though, that someone who is sick or injured will not forego care appropriate to their condition just to attempt to qualify for disability insurance payments. As a result, disputes over whether the insured is under the care of a physician do not often arise. When they do, the insurance company may be mistaken as the court found in the Berg case. For that reason, any disability benefit claimant whose claim is rejected on the ground that they are not under the care of a doctor should immediately turn to experienced, knowledgeable legal counsel for assistance.

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