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Hidden inside every long-term disability insurance policy is a clause that can cause tremendous problems for policyholders who don’t understand the insurance company’s requirements represented in the terms of art of that clause. The language will specify in some way that a policyholder is required to receive “appropriate care” for the condition that has led to a disability.

If you fail to receive care that satisfies the insurance company’s requirements, then you may be considered to have violated the terms of your policy, and you could lose your eligibility for benefits. As a legal team focused on protecting professionals who are relying on disability benefits to cover expenses in a time of need, we’ve seen many times how strict an insurance company can be when it comes to enforcing the “appropriate care” clause in a disability insurance policy.

While policies can vary tremendously and every claimant’s situation is unique, here are some general factors to be aware of with regard to appropriate care clauses in disability insurance policies. If you contact us for a complimentary consultation, we can review the terms of your policy and work to help you understand your contractual obligations and those of your insurance provider.

Understanding the Terms

When you purchase disability insurance, you are entering into a contract with the insurance provider. They agree to provide certain benefits if certain conditions occur. Those conditions should be spelled out in detail in your policy, because if you don’t comply precisely, the insurer will use that as grounds to deny benefits or discontinue paying them.

You need to look at the requirements exactly as they are written, and you need to understand the meaning the insurance company places on the terms they have used. In many policies, the clause might specify that appropriate care must be obtained from an appropriate treatment provider. In other policies, the insurer might demand that an appropriate provider be used but not spell out this requirement in the policy. When discerning the meaning of the requirements, it may be necessary to look in ancillary documents that may be referenced within the policy.

Defining “Appropriate”

Insurance companies can take a very narrow view when it comes to assessing whether a policyholder has satisfied their obligation to receive appropriate care. They may determine that:

• You received care that didn’t match your needs according to their guidelines
• You received care from a provider who was not authorized according to their guidelines
• You did not receive care within the timeframes that the insurance company demands
• The conclusions of your care provider are not accurate because they do not match the insurer’s guidelines
• You failed in your obligation to follow care instructions
• You needed to receive care for an additional condition and failed to do so
• The documentation of treatment provides inadequate evidence that you received appropriate care

Regardless of the reason given for a denial or discontinuance of benefits—or if no reason is provided—it is a good idea to consult a knowledgeable attorney who can help resolve the issue. Sometimes it is possible to negotiate an understanding quickly, while other times, it may be necessary to initiate legal action to encourage the insurer to honor obligations under the policy. 

Insurance company representatives are always looking for justification to reduce what they pay out, and sometimes they act in bad faith or simple ignorance about what they are contractually bound to provide. Attention from an attorney often helps ensure that your claim is examined by someone with a better understanding of the key issues.

Staying in Compliance with Your Policy

To stay in compliance with the appropriate care requirement in your long-term disability insurance policy, the first step is to follow whatever specific guidance is spelled out in the policy. If they require you to see a specialist from an approved list of providers every month, then that is generally what you will be expected to do unless you can present a good reason for acting otherwise (such as if the nearest specialist on their list is 1,000 miles away).

If there is no list of providers and no specific definition of the type of provider you need to receive care from, you (or your attorney) could contact the insurer to ask whether the provider you would like to use qualifies to satisfy the appropriate care requirement. When the policy does not specify the frequency of visits, then determine what the reasonable standard would be for your condition and ensure that you receive care at the appropriate intervals. Keep records of all visits.

If you have questions or are having difficulty understanding or complying with instructions, ask for clarification from the health care provider or insurance company. The medical profession and the insurance company may have different understandings of what appropriate care should be for your condition, and if it is possible to comply with the insurance company’s definition, it can make the claims process easier. However, when the insurance company establishes unreasonable standards, then an attorney can help you demonstrate that compliance with reasonable medical guidelines fulfills the requirements of your policy.

It is also important to follow the recommendations of your care providers and document your compliance if you can. If you are supposed to receive hydrotherapy twice a week, keep a log of your visits. If you are supposed to refrain from certain activities, make sure no one posts a picture on social media of you engaging in those activities. If you are supposed to meet with a physical therapist regularly, record the visits and the time you spend completing exercises at home. Taking a few seconds to jot down notes could potentially make a big difference in your ability to continue receiving benefits if your insurer alleges that you are out of compliance with your policy.

Is Surgery Considered “Appropriate Care?”

While the insurance company cannot force a policyholder to have surgery, it could be possible that the terms of the disability policy are written in such a way that the policyholder would be required to have surgery to comply with the appropriate care clause. Generally, this type of clause would only be enforceable if the surgery at issue is considered to be the standard treatment for the condition, and if the surgery is rated as a low-risk procedure with a high rate of success. If a policyholder believes that the risks of surgery are too great to justify any potential benefits, an attorney may be able to demonstrate that surgery is not required to fulfill the requirements of the appropriate care clause.

Seltzer & Associates Helps Policyholders with Disability Insurance Difficulties

It is unfortunate that insurance companies make it so difficult for policyholders to receive the benefits they have contracted to receive under their disability insurance policies. At a time when you should be focusing on recovery, you instead find yourself mired in uncertainty and conflict with your insurance company. That’s why we established Seltzer & Associates. 

We focus our practice on helping professionals with disability insurance gain the full benefits they are entitled to under their policies. If you have questions or concerns about an issue related to disability insurance, we invite you to contact us for a free consultation. We are based in Philadelphia but serve clients throughout the U.S.