Somewhat connected to the previous post is the issue as to whether an insurance company can threaten to deny benefits unless you have surgery. Think about this. If an insurance company could force insureds to have surgery, they could potentially kill a lot of people! This is why it is entirely inappropriate for any insurance company to threaten benefits because insureds and their physicians prefer the “conservative” approach to treatment.
Unum is by far the biggest offender since, in my opinion, its medical reviewers are arrogant. Even when treating physicians document that it is unlikely surgery will do any good, (such as is often the case with carpal tunnel syndrome), Unum often keeps pushing the buttons to have surgery. Of course, when the company threatens benefits, insureds get scared and consent to surgery even though it is not in their own best interests. This is wrong.
I have always recommended to clients that they should NOT add, or engage in any medical treatment solely because they think it will better their disability claim. Any treatment prescribed by treating physicians and agreed to by insureds is by far a better course then relying on the opinions of insurance medical reviewers based only on paper reviews. Once appropriate treatment is established, the disability claim falls into place. Unlike the objectivity of a treating physician, insurance medical opinions are biased and prejudicial.
Insurance company lawyers should know better than to allow its medical staff to voice recommendations and opinions concerning surgery, appropriate care not withstanding. Insurance doctors are “paper reviewers”, they never see the patient, have no history of consultation or treatment with the insured, and openly classify insureds as non-patients. Even IME physicians are cautioned to refrain from giving medical recommendations because insureds ARE NOT THEIR PATIENTS. IME examinations, as well as internal medical reviews, have an agenda, and it isn’t the health of the insured. Of course, not everyone follows the rules.
A major problem today is that once an insurance company decides to beat up on their insureds about getting surgery, insureds get scared and essentially give in. It’s like playing “dirty pool” or stacking the deck in a game of Texas hold ’em. The insurance company knows it holds a straight flush, and will win the game eventually when insureds throw in their cards and fold.
Bottom line, insureds and their treating physicians do NOT need to give in to insurance demands to have surgery, and should NOT give in if surgery is not in the best interests of the patient. The reasons for conservative treatment should be fully documented and signed off by the treating physician. It’s important to recognize what companies like Unum are trying to do, and that it will be necessary to document everything officially in the file.The solution is not to get scared and have surgery, but to document the reasons why you will not.
If anyone is having any issues on this subject, please feel free to contact me. I’ve managed many claims successfully dealing with this issue. No insurance company should be allowed to dictate medical care under threat of benefit termination.
