The Evolution of Disability Policies
Part 1: Care Requirements

In this series, we will be examining how insurance companies have changed disability policies over time to make it harder to collect benefits. In Part 1, we’ll be looking at care provisions.

Most disability policies require you to be receiving ongoing medical care in order to remain eligible for ongoing benefits. Earlier disability policies typically addressed this requirement in a short, simple manner. For example:

Benefits are provided for the Insured’s total or partial disability only if:

      • the Insured is under the care of a licensed physician other than himself during the time he is disabled

In contrast, newer policies (particularly those sold to dentists, physicians, and other professionals) now have much more stringent care requirements.  For example:


        • You are evaluated in person by a Doctor; and
        • You receive treatment appropriate for the condition causing Your Disability; and
        • Your evaluations and treatment are provided by a Doctor whose specialty is appropriate for the condition causing your Disability; and
        • The evaluations and treatment must be at a frequency intended to return You to Full Time Work; and
        • You must pursue reasonable treatment options or recommendations to achieve maximum medical improvement.

(emphasis added). In addition, some policies hide additional caveats related to your care in other parts of the policy. For example, a policy that contains a definition of “regular care” could also have a “duty to cooperate” provision in another part of the policy that states something like this:

You have a duty to cooperate with us concerning all matters relating to this policy and any claims thereunder. This cooperation includes, but is not limited to . . . 

          • securing appropriate medical treatment for condition(s) upon which your claim for benefit under this policy is based. This includes such corrective/remedial surgery or generally accepted medical procedures which to an ordinarily prudent person would appear medically reasonable for such condition(s).

(emphasis added). When you consider these provisions along with the fact that most disability policies allow your insurance company to request in-person medical examinations, you can see that filing a disability claim is not as simple as finding a doctor to sign off that you are disabled. The process is much more involved than that. In addition to being prepared to back up your diagnosis and limitations, you should be prepared for challenges to your doctor’s treatment plan (and be able to explain why you are not complying with your doctor’s recommendations, if there is a recommended treatment that you are not pursuing).

Every claim is different, and these are just some examples of care provisions taken from different policies. Your policy may contain different and/or additional language that could impact your particular situation.  If you are unsure about the terms of your policy, or how a provision applies to your specific situation, you should contact an experienced disability insurance attorney.


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