What Do Disability Benefits And Appropriate Care Mean?

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By: Bill Henry
PublishedApr 25, 2020
3 minute read

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In an insurance policy, anything that is bolded or capitalized is usually a defined term. You usually have to go to the definitions section to find them. In this policy, it’s under the description of benefits section. So, this is the definition of disability benefits part one.

Part one of the policy

Part one of the policy states, “The insurance company will pay disability benefits if an employee becomes disabled while covered under this policy. The employee must satisfy the elimination period, be under the appropriate care of a physician, and meet all other terms and conditions of the policy.”

Three requirements

So there are three things there. The elimination period that we talked about before, where you had to make it past the first week. “Be under the Appropriate Care…” This phrase is capitalized, so that’s a defined term, which we’ll look at. And then, “Under the Appropriate Care of a Physician…” Again, physician is capitalized, so that means there’s a definition for that. Of course, you also have to comply with all the other terms and conditions of the policy.

Appropriate care

“Appropriate care means the employee has received treatment, care, and advice from a physician who is qualified and experienced in the diagnosis and treatment of the conditions causing the disability. If the condition is of a nature or a severity that is customarily treated by a recognized medical specialty, the physician must be a practitioner in that specialty.”

So if you are claiming disability due to depression or another psychiatric condition or a mental illness, the insurance company thinks that you should be treated by a psychiatrist if the condition is indeed disabling. And if you have a concussion or a traumatic brain injury, the insurance company thinks that you must be treated by a neurologist.

Insurance companies are generally very conservative. Perhaps chiropractic care, acupuncture, physical therapy, or other modalities of treatment may be helping you recover from your conditions. However, in order to fall under the definition of appropriate care, you must see a medical doctor in the specific specialty.

You must continue the treatment as required

Part two continues as follows, “You continue to receive such treatment, care or advice as often as is required for treatment of the conditions causing disability.” So, if you’re seeing a psychiatrist and the psychiatrist says, “Let’s see how these medications help. Return to me in 30 days or 60 days,” well, then you need to go back by the time that the doctor tells you to return.

The same is true for a neurologist. Sometimes, neurologists don’t do much in terms of active care of a traumatic brain injury. They might just say, “Return to me in three months. Return to me in four months. Return to me in six months.” And if that is what your doctor has told you to do, follow your doctor’s orders. Yet at the same time, the insurance company cannot tell you to go more often.

Adheres to the prescribed treatment plan

Part three specifies, “Adheres to the treatment plan prescribed by the physician including the taking of medications.” Medications have lots of side effects. And you may be affected by a side effect of a medication that’s been prescribed for treating your condition.

If that is the case, you need to communicate that to your doctor, call him or her, and say, “I’m having these side effects.” And then the two of you need to discuss whether or not you should continue with the prescription, stop the prescription, or change to a different prescription.

You can’t just stop taking your medication. Your doctor is not going to like that anyway. But the insurance company is requiring you to follow what your doctor is saying, including taking the medications. So, that is just the definition of appropriate care.

Definition of a physician

Now, let’s talk about the definition of physician. A physician is defined as, “A licensed doctor practicing in the scope of his or her license and rendering care and treatment to an insured that is appropriate for the condition and locality.” So, again, you need to see a licensed doctor, not an acupuncturist or a chiropractor.

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