When the insurance company is reviewing your long term disability claim, they will be evaluating your credibility. They will be looking to see if the evidence you provided proves that you have been truthful about your symptoms, pain levels, and inability to work.
The most common way the insurance company checks this is to see whether you sought treatment for your disability. Naturally, if you have not seen a doctor about your disability, you will have no evidence to support your claim, and you will be denied. The meaning of “treatment” is more than just an initial visit to the doctor for a diagnosis. “Treatment” refers to the continuous amount of time that you will need to see doctors, take medication, have physical therapy, lab work. This is also referred to as your treatment plan.
Your treatment plan will cover not only the necessary doctor visits and medications; it will cover your use of assistive devices like a cane or wheelchair, neck or back braces, etc.
The claims adjuster will ask you questions such as:
- Have you been filling your prescriptions when they are ready to be refilled?
- Are you using your assistive devices as prescribed by the doctor?
- Are you keeping your appointments?
The insurance company will also check to see if you have been truthful. They will review your prescription refill history. They will hire a private investigator to record you to make sure you are using your assistive devices. They will request a print out of appointments from your doctors to be sure you are keeping your scheduled appointments. These are easy ways for the insurance company to deny your claim. Don’t fall into the trap!
Likewise, if you avoid following the treatment plan as prescribed (like refusing to have surgery), the insurance company may claim that you are refusing to do what you need to to get better so you can work and deny your claim for that.
However, there are some exceptions. You are not allowed to be denied for failure to comply for the following reasons:
- You cannot afford the treatment. (More on this below)
- The side effects of the medications are making your symptoms worse
- The medications from different doctors are causing side effects to be worse
- The prescribed medicine is against your religion
- Your doctor says no treatment options will work for your disability
- The treatment plan involves very addictive substances
- The treatment plan involves amputation
- The treatment plan includes an experimental treatment not proven to work
What if I am struggling financially and can’t afford to see my doctor?
Co-pays for medications and doctors’ appointments get expensive when you are being treated for a serious injury or illness. However, if you do not make your appointments, the insurance company will imply that you are really not that sick or injured. They will say that if you genuinely were injured, you would have to go to the doctor for treatment and since you missed your appointments, you must be better, and thus able to return to work.
This is just another trick that the insurance company uses to avoid paying claims. Work with your doctors to come up with a payment plan that keeps you from having to stop seeing them. Look into additional options for help with prescriptions like GoodRX or talk to your doctor about making sure the only medications that they prescribe are absolutely necessary and are only available by prescription. For example, if diarrhea is a side effect, ask them to let you use an inexpensive over the counter alternative if possible.
In conclusion,
Finances are a primary reason why people do not follow their treatment plans. However, if you do not prove that you have exhausted all your financial efforts to afford your treatment plan, you can still be denied. Keeping your appointments and using your assistive devices are equally important.
If your claim has been denied the experienced disability attorneys at the Ortiz Law Firm can help you through every step of the process, from administrative appeals to a potential lawsuit. They only get paid if you win. You can seek help without worrying about upfront costs or unexpected bills. Our law experts will focus on your case so you can focus on your illness.
The Ortiz law firm has successfully represented people in disability cases across the United States. To see how we can help you win your long-term disability case, call us at (888) 321- 8131.
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