Defining and Decoding “Appropriate” Care

Disability insurance claim examiners often bring up the issue of “appropriate care” when questioning benefit claims and often use this same term as an excuse to deny claims.  Many claimants do not properly understand this term and how it can be used by the insurance company to manage your disability claim.  Older disability policies used to require that a claimant be under the “regular care” of a physician and required little more.  As insurance companies seek more control over disability claims and their direction, this policy language has been changed to “appropriate care,” which has a much more stringent definition.  Regular care was usually based on a time perspective, ensuring disabled claimants were receiving some sort of recurring medical treatment.  The shift to “Appropriate care” has given the insurance companies the liberty to retain their own experts to decide if the claimant’s choice of treatments or physicians is “appropriate” for the condition. 

The motivating factor behind this change is control of your disability claim.  If insurance companies have the latitude to decide what care is (or isn’t) appropriate, they can influence your medical care and treatments with the goal being to reduce the length and amount of the claim, either by discounting the medical support presented by the claimant or by making a disabled claimant return to work no matter the treatment risks or if the claimant is actually ready and able.  Several factors are taken into account by the insurance companies when determining appropriate care.  Knowing these factors and what to look for can allow you to receive the appropriate care from professionals of your choice rather than that dictated by the insurance company.

What type of doctor can “appropriately” treat me for my condition?

Always choose a doctor who specializes in the field of your disability to obtain a diagnosis.  General practice or family practitioners are often deemed to be less qualified than specialists in certain fields by insurance companies to be the treating physician for a disability claim. This does not mean that those doctors aren’t able to treat your condition – they very well may be the best choice for you.  But be aware that your disability insurance company may not find them acceptable, creating an obstacle to getting your claim approved.   For example, we recently had a client who was receiving treatment for depression from her general physician.  Although they had a long standing relationship and the claimant’s condition was improving while receiving all the care she needed, the claims examiner wrote that the insured was not receiving appropriate care and treatment because she wasn’t being treated by a board-certified psychiatrist.  Not too surprisingly, the insurance company came to this conclusion based on a report written by a board-certified psychiatrist on their payroll.

When do I need to visit my treating physician?

Most policies expect that a claimant will visit their treating physician at least once a month.  In addition, the physician must fill out the insurer’s questionnaire, attending physician statements, or claim forms, which usually includes questions asking if the claimant is able to return to work.  It’s important to note that your general physician appointments may not count as regular visits for your condition if you were diagnosed by a specialist.  You must visit the doctor that diagnosed your condition or another doctor who specializes in the field.

Do I have to follow every single one of the treatment recommendations?

This is a question that claimants inevitably ask.  For example, many people don’t like surgery (but then again, who does) and will avoid surgery at any cost.  This can raise problems in disability claims caused by Carpal Tunnel Syndrome.  There may be surgical options as well as more conservative methods to treat Carpal Tunnel, but the insurance companies usually expect or demand Carpal Tunnel Release surgery because it may get the claimant back to work and off claim more quickly.  But again, many people don’t want surgery and will pursue other therapies.  Insurance companies have denied disability benefits by asserting that those claimants didn’t receive “appropriate” care.  If you intend on also using more conservative or alternative treatments for your condition, be prepared to provide a well-based medical opinion of why those treatments should be considered acceptable and appropriate.

Redefining “appropriate care” is another way insurance companies are trying to manage every aspect of disability claims to pay the least amounts of benefits for the shortest periods of time.  The scary part is that this policy language can allow them to manipulate your health and well-being, far outside the scope of your disability policy.  To retain control of your treatment and your health, it’s important to know what is considered appropriate and obtain the proper advice, care, and treatment before the insurance company tries to decide it for you.

If you have any questions about how the insurance company will view your current treatment plan or need advice on how to seek the proper physician, please take advantage of our free consultation or call our offices at (855) 828-4100.

14 thoughts on “Defining and Decoding “Appropriate” Care

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