The Edge Series: What is “Regular and Appropriate Care”?

The lawyers in our firm are focused on helping people with disability policies and ERISA claims. We want to give you the edge in understanding your policy. Today, we want to help you understand what the term “regular and appropriate care” means in your disability policy.

“Regular and appropriate care” refers to the medical care that would be appropriate for the disabling condition that you are experiencing.

If the care is needed to monitor and improve your condition, then you should make an effort to get the treatment.
If you are not receiving treatment appropriate for your condition, then your claim could be denied or terminated. That would be the case even if you cannot afford to go to the doctor. Most policies require that you receive regular and appropriate care.

The question remains as to how often you must go to your doctor. The frequency of your treatment depends on the medical standards for managing the condition(s) that caused your disability.
For some conditions, that may be one visit per month. For others, that may be one visit per year. The frequency will depend on what your physician says is necessary to monitor and treat your condition, as long as that opinion is backed up by generally accepted medical standards.

Policies may have a provision waiving that requirement if further care would be of no benefit to you.
For example, someone diagnosed with radiculopathy and is prescribed pain medication would need regular ongoing medical care to verify control or monitor that condition. Someone who has terminal cancer and who will not likely live for six more months may not need regular care. Following your doctor’s advice is very important.

One danger that is common is when the insurance company does not agree with the doctor’s level of care.
I have seen claims denied because a doctor did not apply more aggressive medical care such as injections, surgery, or stronger pain medication. For example, if a physician knows a patient will refuse opioid medication due to her own desires and only prescribes Ibuprofen, the insurance company may infer that the pain must not be that significant. They may contend that the appropriate standard of care for significant pain was not met. Clearly, that is not fair.

Remember our ERISA attorneys and long-term disability lawyers are here to help if you run into problems. Contact us at the first sign of trouble with your disability claim.

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