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In literal terms, an insurance company cannot require a policyholder to do anything. But, as a practical matter, insurance companies often wield significant power. 

We purchase insurance to protect us in times of emergency, and when an emergency occurs, we rely on the resources provided under the insurance policy to keep us in good financial condition. So, if the insurance company says we need to do something in order to receive payments, we generally try to comply.

For instance, if the company that provides our disability insurance requests copies of test results and examination records from a specific date, we would submit them as quickly as possible. If the insurance company says we need to follow the doctor’s instructions for returning for follow-up care at specified intervals, we would comply.

But if the insurance company makes a much more drastic request, then it is important to give careful consideration before complying. So what happens if the disability insurer insists you need surgery? If you contact us directly for a free consultation, the team at Seltzer & Associates can provide an answer based on the specific details of your policy obligations. We cannot undertake that type of analysis in a blog like this. But here we can explain some of the general factors involved when the insurance company expects a disability insurance claimant to undergo surgery.

Policy Requirements

It would be highly unusual for a long-term disability insurance policy to state flat out that a claimant must agree to have surgery in order for disability benefits to continue. But the obligation may be present in a more hidden form. Discerning the meaning behind the words of an insurance policy is sometimes like decoding a secret language—if you don’t have the code or don’t know the language, you won’t understand what the letters on the page actually mean.

Most disability insurance policies will contain language requiring a claimant to receive “appropriate care” from an approved medical provider, or to be “under the care of” a medical provider. This seems simple and straightforward but it is not.

First, you need to consider the type of medical provider that will satisfy the insurance company’s expectations. Do they require you to see a specialist? How specialized does the specialist need to be? Are certain credentials required?

Next, it is necessary to understand what is involved in being “under” that professional’s care. How often are you expected to see the doctor? Do telehealth visits count? And what if the doctor offers a choice? If you choose the option that is not the doctor’s first recommendation, are you still receiving appropriate care, or have you rejected that care?

Often, insurance companies insist that the latter statement is true. They might inform you that refusal to have surgery means that you have chosen to remain disabled and that, therefore, you no longer qualify for benefits. Or the company might say that you are obligated to receive care designed to “lead to a cure, alleviation or minimization” of the disabling condition, and that by refusing surgery, you are violating this provision of the policy.

If the insurance company makes this type of argument and the policyholder does not respond effectively, the insurance company will win. But a knowledgeable disability insurance attorney will know how to refute these assertions, and that can allow a claimant to receive benefits even without surgery.

Weighing Risks and Benefits

An ethical healthcare provider conducts a risk-benefit analysis before issuing a treatment recommendation. For example, if a patient has a broken leg, one way to address the problem would be to amputate the leg because then there is no more broken bone to be concerned about. This was standard medical treatment at one time for certain types of fractures because of the risk of infection. However, with modern medicine, the risks and detriments of this procedure clearly outweigh the benefits.

The same risk/benefit analysis can be applied to surgery. A surgical procedure can be risky for a wide variety of reasons:

• The patient might have difficulty tolerating anesthesia
• The patient might have a condition that impedes healing after an invasive surgery
• The surgery might provide only temporary relief
• The surgery might have a low success rate
• Alternative treatments might have a success rate that is similar to surgery
• The surgery might carry a great risk of complications

In addition, the treating physician might believe that the relief provided by surgery might be undone if the claimant returns to work and performs the same tasks that caused the injury in the first place. Before deciding to have surgery, it is important for a patient to have thorough discussions with healthcare providers to address these issues and specific concerns about the details of the patient’s condition and the type of surgery under consideration.

When the risks clearly outweigh the benefits, an experienced attorney should be able to advocate successfully to prevent the insurance company from denying benefits solely because of a refusal to undergo surgery. When the history of the procedure suggests that the benefits justify the risks, it becomes more difficult, but not impossible, to make that argument.

How a Lawyer Can Assist with Unreasonable Disability Claim Requirements

Most people have had some experience filing an insurance claim under an automobile or homeowner’s insurance policy, and they expect disability insurance to operate the same way. It does not.

Claim denials have essentially become the default reaction when a policyholder files a claim, particularly under long-term disability policies. At the very least, insurance companies shift the burden of proof squarely onto the policyholder. Instead of providing a thorough explanation for why they are refusing to pay what is expected under the terms of the policy, the insurance company demands that the claimant prove, in no uncertain terms, why they are eligible to receive benefits.

While this is grossly unfair, it is not likely to change anytime soon. When a professional suffers from a disability that prevents them from working, it is often necessary to work with an attorney who focuses on disability insurance issues in order to recover full benefits under a disability insurance policy.

Attorneys who work with this type of insurance know the nuances of the law and when insurance companies have crossed the line into bad faith. They know how to interpret policy language to determine the specific obligations of both parties. An insurance company may issue form letter rejections of a policyholder’s claims, but if they receive a letter from a knowledgeable attorney, they suddenly start looking at the claim more closely. When an attorney has a reputation for success in litigating insurance disability claims, the insurance company is usually more amenable to settling the claim fairly to avoid the expense of a court case.

Seltzer & Associates Understands How to Help You Bridge the Gap to Recovery

When you are not able to work because of a disability, you need to focus on recovery, not worry about deciphering insurance terms in your disability insurance policy. The team at Seltzer & Associates has decades of experience working with disability insurance claimants to help them receive the full benefits they deserve. If you need to file a claim, you’ve been denied, or you are concerned that benefits could be discontinued, we invite you to contact us for a complimentary consultation to learn how we may be able to assist.