My Disability Company Told Me To Have Surgery–
Can They Do That?

Can my insurance company make me have surgery or dictate the terms of my treatment?

This is a common question, and a complex one. The answer depends on the terms of your policy and your disabling condition. Recently, insurers have become more aggressive in this area. The case of Jue v. Unum is one such example.[1] 

What if My Doctor Disagrees About Surgery?

Dr. Jue, a dentist, filed a claim in 1991 based on pain and swelling in both of her wrists, attributable to De Quervain’s Tenosynovitis.  Dr. Jue’s physicians indicated that surgery was an option in some cases but more conservative treatment was warranted.  Dr. Jue was reluctant to have surgery given her age and surgery risks.

Notably, Dr. Jue was on claim for many years before Unum brought up surgery, including a prolonged period from 2004-2011. Despite knowing that surgery was a potential option for De Quervian’s patients, Unum continued to pay benefits for a fifteen-year period.  In fact, one Unum representative even told Dr. Jue in a phone call that they could not force her to have surgery.  Yet, in 2017 Unum took the opposite position and told Dr. Jue that she had 90 days to schedule her surgery. If she did not, Unum told her that it would terminate her claim for failure to “obtain appropriate treatment for her condition.”

In response, Dr. Jue returned to one of her treating physicians, Dr. Hsu. Dr. Hsu opined that Dr. Jue had legitimate reason for concern, because no surgeon could guarantee that surgery would improve her condition. Dr. Hsu also stated that no surgeon could guarantee that surgery would not make her condition worse.  Unum then secured its own set of physician opinions who said that surgery was the next appropriate treatment, and terminated the claim in spite of Dr. Hsu’s opinion.

The Takeaway:

As of the date of this post, Dr. Jue’s case remains ongoing. However, her case shows that insurers are willing to make surgery a requirement for ongoing benefits. This does not necessarily mean the insurer is right, but it may mean that a lawsuit is necessary to resolve the question.

If your insurance company is pressuring you to have more invasive treatment than you are comfortable with, please feel free to contact one of our attorneys directly.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your claim has not received a full and fair review, an experienced disability insurance attorney can evaluate your claim and help you determine what options are available.

[1] Jue v. Unum Group, Case No. 19-CV-08299-WHO, 2021 WL 427640 (N.D. Cal. Feb. 8, 2021).

 

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