Can Infrequent Medical Treatment Endanger My Disability Benefits?

Disability Wiki.

There are many reasons why you may decrease your treatment.  You may stop treatment or treat less frequently because your doctor relocated or retired, your insurance changed or expired, or your symptoms just made it too difficult to treat regularly.  Irrespective of the reason, infrequent treatment will likely raise a red flag that may endanger your long term disability benefiits.

Your Insurer May Assume You Don’t Need Treatment

If your insurer discovers that you stopped treatment – or finds there are long gaps between treatment dates – your insurer may conclude that your condition simply isn't severe enough to warrant treatment or keep you from working.  Insurance companies seldom bother with attempting to find red flag medical evidence disability claimother reasons which might have led you to stop your treatment. Generally, they will latch onto gaps and conclude that if your symptoms aren't severe enough for frequent treatment, then they aren't severe enough for you to require benefits.

This can be especially problematic if there is nothing treatment can do to help your medical condition, and your doctor is the one who recommended less frequent treatment.  In that case, it may be helpful to get a letter from your doctor explaining why frequent treatment is neither helpful nor necessary.

Your Insurer May Assume You Experienced Medical Improvement

In some cases, the initial medical evidence is so strong that the insurance company will agree you're disabled and grant your long term disability benefits. But, after this, the insurance company may carefully monitor your treatment process and look for any gaps or inconsistencies.  If the insurer finds any gaps or inconsistencies, the insurer may assume that your condition has improved – perhaps even to the point of returning to work.

A common argument the insurance companies make is that, if your condition remained the same, you would be receiving the same amount of treatment, if not more.  For example, the insurance company may point to less frequent physical therapy sessions to claim the prior sessions must have restored function and improved your symptoms.  As another example, the insurance company may point to less frequent pain management appointments or lower doses of pain medications to claim that your pain must have improved.

Your Insurer May Assume You’re Disinterested in Getting Better

Treatment can be frustrating, painful, time-consuming, and expensive.  When someone is treated for a prolonged period without experiencing any changes, it’s not difficult to understand why he or she may treat less frequently or give up on treatment altogether.  Unfortunately, your insurance company may assume that if you’re not willing to put in the work to get better, your condition must not be severe enough to disable you.

Alternatively, the insurance company may point to gaps in treatment as “evidence” that you simply don’t care about getting better and would prefer just to stay home and collect benefits. Most insurance companies will not hesitate to attack your character and credibility if it helps them save money by denying your claim.

Your Insurer May Claim You're Being Non compliant

If your doctor recommends frequent treatment, the insurance company may interpret less frequent treatment as “noncompliance” with your doctor’s treatment plan.  The insurer may argue that the recommended treatment frequency may have helped you, and by not following that plan you're purposely sabotaging your potential for improvement – all to remain on benefits.

Your Insurer May Assume That You're “Doctor-Shopping”

If the insurer identifies gaps in treatment when you've switched doctors, the insurer may assume that you did this because your first doctor didn’t support your disability claim.  In other words, the insurer may accuse you of actively looking for a doctor who will support your disability status.  The long term disability insurance companies call this “doctor-shopping.”

The insurance company will seize on any opportunity to attack your credibility and accuse you of “doctor-shopping.” Of course, there are many legitimate reasons why people switch doctors.  For example:

  • Dissatisfaction with treatment
  • Dissatisfaction with bedside manner
  • Dissatisfaction with technology and testing available within the medical practice
  • Changes in insurance
  • Convenience of location
  • Hours of practice and availability of the doctor

If you're worried your insurance company may accuse you of doctor-shopping, consider avoiding major gaps in treatment and explaining to the insurance company why you switched doctors.

Your Insurer May Demand an Independent Medical Examination

If the insurance company identifies insufficient evidence, missed appointments, or lack of compliance with treatment, it may demand an Independent Medical Examination (IME) with one of its doctors. The problem, of course, is that this examination is anything but independent. The IME doctor is hired by the insurance company and therefore operates under a direct conflict of interest.  Typically, the IME doctor will only perform a cursory evaluation before concluding that you're capable of working. Then, the insurance company will rely on the IME’s report as “evidence” that you're not entitled to long term disability benefits.

Your Insurer May Claim Your Doctor’s Assessment Is Unreliable

Sadly, missed appointments and infrequent treatment may discredit the reliability of your own physician’s assessment.  For example, the insurer may claim that your doctor isn’t familiar enough or qualified to comment on your disability status because he or she doesn't see you regularly.  This may also lead to the insurer’s demand for an IME.

Why Infrequent Treatment Could Hurt My Long Term Disability Benefits?

Gaps in treatment raise red flags that can substantially complicate your long term disability claim.  Infrequent treatment – especially without explanation – can create an opportunity for the insurer to attack your credibility, character, and eligibility for long term disability benefits. To avoid these problems, it is very important to remain in consistent treatment and follow your doctor’s treatment plan.  Treatment is one of the best weapons for obtaining and maintaining your disability.  If you don’t follow your doctor’s plan, you should be prepared to explain why.

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