Standard for overriding doctor?

[gmcgann]

What is the name of your state (only U.S. law)? NC.

I was placed on short term disability resulting from extensive shoulder surgery. After the operation my surgeon wrote in his notes that a return to light duty might be possible in 6 weeks, but regular duty was at least 4 months out. After three months the insurance company decided that the doctor's conclusions were not warranted by the medical notes, and denied my claim. My doctor is sticking by his recommendation, and my employer will not let me return until released by my doctor with no restrictions.

The policy says I am disabled if I am unable to perform all the regular functions of my job. My doctor says I cannot, the insurer says I can. They said they needed to talk to the surgeon, left two messages on his voicemail, and when the surgeon got their voicemail on his callback they declared their responsibility to talk to him ended.

My question - is there a standard or any relevant case law concerning when the insurance company can override the doctor's opinion? I'm caught in the middle of this since I cannot return to work even if I want to. My job is safety related (air traffic control, contract, not FAA) and I can't work until the doctor clears me unrestricted.

Thanks.

 

[ecmst12]

You need to review the policy and find the appeals procedure.

Has an IME been ordered? Have you been seen by someone other then your treating physician who says that your condition right now at this moment is such that you can return to work? Or has your doctor just not submitted sufficient documentation showing that you are NOT fit for duty? Your doctor is going to have to follow up here and make sure the notes that he submits to them are accurate.

 

[gmcgann]

Thanks for the reply. My doctor has tried to get in touch with them several more times and been unable to do so. I've consulted an attorney and filed an appeal.

What made this problem as bad as it's gotten is that Cigna told me they were working as hard as they could on my claim for almost a month, and just to be patient. When they finally denied it I was only 2 weeks away from returning to work, which will be this Friday. They delayed until getting a second opinion was a moot point.