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Provident Life Says Disabled Doctor Must Undergo Surgery or Lose Benefits

Disability Claim Denials

A disability insurance policy may condition a doctor’s disability benefits upon his consent to receive “appropriate” medical treatment, which may include surgery, according to the California court in Provident Life & Accident Ins. Co. v. Henry.

In Henry, a disability insurance company, Provident Life, sued its insured, a disabled podiatric surgeon, after he did not comply with its demands to undergo carpal tunnel syndrome release surgery.  Provident Life argued that the “appropriate care” provision in the disabled doctor’s disability insurance policy required him to submit to surgery.  The appropriate care provision stated that in order to receive disability benefits the insured must also “receiv[e] care by a Physician which is appropriate for the condition causing the disability.”  Provident Life argued that carpal tunnel syndrome release surgery was appropriate in this case because (1) other more conservative treatments had failed, and (2) the surgery was a low-risk procedure (3) that had the potential of curing the doctor’s disability thereby enabling him to practice again.

The disabled doctor disagreed with Provident Life’s interpretation of the appropriate care provision.  He argued that, absent explicit policy language alerting an insured of a potential obligation to submit to surgery, Provident Life could not demand he undergo surgery.

Thus, the issue before the California court was whether or not an appropriate care provision may condition benefits upon a disability claimant’s consent to undergo surgery.  The California court held that it may.  An appropriate care provision may “create a duty to submit to appropriate medical treatment which, in some circumstances, may include a surgical procedure.”  In this case, the California court concluded that there was a triable issue whether or not carpal tunnel syndrome release surgery could be considered “appropriate care” under the circumstances; therefore, the parties would present the issue at trial for the jury to decide.

Most, if not all disability insurance policies contain an appropriate care provision.  California courts consistently construe these provisions to include a potential requirement to submit to surgery when doing so is “appropriate” (for another, example of how California courts may construe an appropriate care provision, read this blog post).  However, what is “appropriate” is arguable in almost every case.  If your disability insurance company is threatening to withhold your disability benefits on the condition that you submit to surgery, you should contact a disability insurance attorney.

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