Disability denied due to regular care

[pooh1965]

I have been on disability as of Aug, for stress/anxiety and depression. I received three weeks of benefits from my short term disability, however they denied further benefits based on i have not been under the regular care of a physician, stating my physician returned me to work in Sept. My physician did not return me to work, nor had he filled out the required return to work paperwork. He stated he would refer me to a specialist, but failed to follow thru on this referal. (thus, the 6wk period or lapse in physician visits which the disability company is basing my denial on---however, I did speak several times on the phone with the physician and or staff, during this period of time I did not visit his office personally)... wouldn't this be considered patient/physician consultation, or under the care of the doctor)? I then sought treatment thru a new physician and therapist, both of whom have placed me on disability for aprox 6 mos- 1yr. What constitutes "being under the regular care of a physician"? What time frame must a patient visit a physician to be considered under physician care ie: once a week, once a month etc ? Any suggestions or advise would be greatly appreciated. Thank You ! Arizona

 

[ALawyer]

This is a common problem. Insurance companies get hit with heavy mentally based claims, particularly when times are tough, and try hard to get out of paying them.

If YOUR doctor failed to follow thru, that failure is attributed to you.

Now as to what is regular care, it is a matter of feel, not fixed rules. Clearly there need not be a daily visit or hospitalization. But a doctor must be monitoring and providing some level of attention, such as prescribing medication. It is not necessary to make efforts that will be futile, but just sending you home to do nothing for months would likely not be under the care.

Three bits of advice:

1. Try to follow the plan to the letter.

2. Watch the dates to file an appeal.

3. It may make sense to get a lawyer to write a letter n your behalf so they don't run over you. If this is an employer based policy there likely is an ERISA exemption from bad faith claims.

 

[pooh1965]

disability denial question

Thank you for your advice. I am currently in the appeals process, of which will be determined sometime this month. I had several phone conversations with the doctor/staff during this 6 wk period, and several phone messages from them as well, of which i copied and sent to the insurance co as proof that i was in contact with the doctor and vise versa. if this is the "sole" reason for my denial of benefits, could this type of "care" via phone consultations prove as being under his care? also, in regards to my question above, if my doctor did not return me to work, by not filling out the required fitness for duty papers, then it can be proven that he did not return me to work (regardless if he is telling the insurance co he did return me to work), and 6 wks later at my appt he did notate my disability, then wouldnt this be proof that i am still or was still disabled during that 6 wk period? my current physician and therepist both have heavily notated i cannot return to work at this time, however the disability co is not accepting their medical notes, stating this is a continuous claim and they are going by what the first doctor stated to them that he returned me to work in september..but once again, that doctor failed to release me back to work...(would this be a suit i would need to persue thru medical malpractice/negligence?) .....i cant find an ERISA atty in this area willing to help me. I am in need of an atty to write a letter ... any suggestions? thank you again for your time...