How Claimants Accidentally Destroy Their Own Disability Cases

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Why not getting regular medical care or following treatment recommendations can doom your disability insurance claim.

Most if not all disability insurance policies or plans require that the policy holder or the plan beneficiary be under the regular care of a physician and follow treatment recommendations.

Now, each plan or policy can have a different definition of the term regular care, and that can make or break your case.

You need to get out your disability policy or plan and read it cover to cover, but particularly pay attention to definitions like regular care.

A disability carrier plan can deny your claim on the basis that you didn't meet those policy requirements, and they don't even get to the issue of whether in fact you are disabled.

They'll just simply say you violated that particular policy or plan provision, and this is one of the disability carrier plan's favorite defenses.

It's an absolute bar to getting disability benefits.

So let me give you an example in the case of Jones v. UnumLife.

Uh, this is a case where Jones began working for Whole Foods in 2018 as a team receiver, and he participated in Whole Foods' employee distri- uh, disability benefit plan, which was insured by Unum.

And in 2022, he stopped working because of back pain.

He was approved for his short-term disability benefits.

Then he was paid a few weeks of long-term disability benefits before Unum denied his claim.

Now, the denial letters never raised the issue of whether Jones had been under the regular care of a physician and the fact that he had absolutely no medical treatment for nine months.

But guess what? When Jones filed a lawsuit, Unum raised this defense.

Jones argued that Unum violated ERISA's law and regulations by failing to raise this regular care issue in its decision letters.

Unfortunately, the court disagreed and found that the failure to raise this defense didn't prevent the court from considering whether he met the regular care requirements for being disabled.

Now, I disagree with the court's ruling.On that particular issue.

I think that was a clear violation of ERISA regulations, but I wasn't the judge in this case.

Jones argued that the lack of medical care and failure to follow the treatment recommendations, including getting physical therapy and an MRI, was a red herring because Unum's failure to pay his benefits prevented him from affording getting continuous medical care.

Now, the court didn't buy that argument.

The courts concluded that Jones essentially stopped receiving treatment and didn't follow treatment recommendations, rejecting his argument that it was financial hardship that prevented him from getting the care.

Now, the court also noted that other courts had addressed this very question of whether financial hardship can excuse the regular care provisions of a policy or plan.

Now, even if the argument was going to be permitted, the problem here was that Jones hadn't offered any evidence to establish the financial hardship to prevent him from obtaining that care.

In fact, the court noted that he was receiving, for this period of time, a-- he was getting his health insurance benefits through his employer's group plan.