Appropriate Medical Doctor is Key to Long Term Disability Approval

Hi, I'm Attorney Cesar Gavidia, and I'm here with Attorney Rachel Alters. And what we want to talk to you about today is treating with your specialist and seeking appropriate care under the disability policy. Now, we've gotten a few calls lately where the person was terminated, their benefits had been terminated, and it had been some time since they'd actually seen their specialist. They'd been treating with a primary care physician. And one of the problems in that particular case was that they had no specialist treatment for almost eight years. And the insurance company, unsurprisingly, had gone to one of their board-certified physicians who were board-certified in the specialty for the condition that they were claiming disability from, and that doctor opined that this person was fine to go back to work, and their benefits were terminated. Now, have you seen that, Rachel, where that's occurred? It happens a lot of times. I have a lot of clients who have MS who are followed by their neurologist for years and years and years. And a lot of times, there's really not much the neurologist can do for them anymore, other than just watch them. There's no other treatment. Sometimes, it's just a chronic condition. So they get released by their specialty doctor, such as a neurologist, as they can't do anything else for them. And my clients will say, well, I haven't been to my neurologist in years, but the insurance company is doing a review, saying that now, according to their higher neurologist, they're not disabled. So that's what the problem is. So what does that person do when, as you described, their specialist, their neurologist has released them and said, look, there's nothing more we can do, and their primary care physician is following their disability claim, and they're filling out their forms every few months or however long, however periodically they have to complete those forms. And what do they do? I mean, are they now basically out of luck, or should they go back to their, you know, find a new neurologist, or go back to the person that saw them eight years ago? I mean, how do they deal with that? It's a difficult situation, because usually, I tell my clients to go into their doctors to schedule an appointment and sit down with them and explain to them that they are on disability, as their doctor should know, and that in order for them to continue disability benefits, they have to be seen by their specialist at least every three to six months. And if their neurologist or other doctor is not willing to do this, they may need to go find another one. And what do you think that the specialist provides in a disability claim that a primary care physician can't provide? In other words, you know, what is that level of detail or that additional piece of evidence or support that they're providing that a primary care physician isn't essentially providing? Well, a specialist knows what to look for. They know what kind of test to order for your condition, whether it's MS or any other special condition. If you have a back condition, you need to see an orthopedist. Who knows what MRIs to order? Who knows if you need spinal injections or surgery? A general doctor, you know, they can generally test you, you know, they test your blood, they can test your blood pressure. They see you for general problems, but they can't handle the specialized issues. And they're not qualified to do so. And the insurance companies will use that against you if you try and just rely on your primary care physician's opinion. Right. It's like going to battle. The insurance company's coming in with cannons and you're going to battle, you're going to war with sticks, right? Exactly. So, and also there's a lot of these policies that actually require you to be treating with a specialist. And if once the insurance company discovers, oh, this doctor that's been completing these forms is just a primary care doctor or an internist, they now will claim that you're not in compliance with the terms of the policy, not seeking appropriate care, not treating with a specialist qualified to treat you for the condition you're claiming disability from, right? Right. I have a lot of clients who have fibromyalgia and a lot of the insurance companies will deny them based on the fact that they haven't been treating with a rheumatologist, that they've just seen a primary care doctor and that's not acceptable under the policy language and they will deny you based on that a lot. So clearly if you're having this issue, if the insurance company is taking issue with who you're treating physician is, that you haven't seen a specialist in some time, you may want to give us a call. We'd be happy to discuss your claim with you and hopefully give you the options you need to move forward with your disability claim effectively.