Navigating a disability claim can feel like being stuck in a hamster wheel, between your doctor, your employer, your insurer, and your case manager. Each may have a different opinion about your ability to work, leaving you unsure who to trust.
A common and critical question arises: Do you have to follow medical recommendations made by your insurance company?
The short answer is no, but with important legal nuances.
In this guide, we explain your rights when dealing with disability insurers in Ontario, including when you can refuse medical advice, how the “duty to mitigate” applies, and what steps to take to protect your benefits.
The “disability wheel” explained
When applying for disability insurance benefits, you may find yourself caught in what cn be described as a “disability wheel”, involving four key players:
- Your doctor
- Your Insurer (case manager)
- Your employer (human resources)
- You (the claimant)
Conflicts often arise, for example:
- Your doctor says you cannot work
- Your insurer may say you’re ready to return to work
- Your employer may dispute reasonable workplace accommodations.
Who do you listen to, and who is right? Understanding who has authority and who does not, is essential to protecting your claim.
Can you legally decline medical recommendations from your insurance provider?
Yes, you are not legally required to follow medical recommendations made by your insurance case worker.
Once you make a claim for disability benefits, you will be assigned a case worker by the insurer.
The case worker is responsible for:
- reviewing your medical documentation
- Applying it to the policy definition found in your disability benefits booklet
- Claims adjudication
Essentially, the case worker job is to evaluate whether your medical condition stops you from doing your job.
They are not a medical provider and should not be providing you with any medical recommendations as they are not qualified to diagnose or treat you.
Instead, you should be listening primarily to your doctor’s recommendations. You are not required to ignore your diagnosis and symptoms and force yourself back to work and risk making your condition worse, just because your case worker believes you should return to work.
Key takeaway
You should rely primarily on the advice of your treating physician, not your insurance provider.
Why insurance companies push “medical” recommendations?
Insurance providers have many avenues to deny your claim. Some can be found written in your disability insurance policy. They rely on the policy language to deny you claim or push medical recommendations.
One common example is the requirement under most long-term disability policies, where a claimant is required to be under “active and ongoing care”.
The problem:
- The policy does not define what “active and ongoing care” means.
- It is open to interpretation
- It can be used to justify denying claims
Does seeing your doctor once a month satisfy this provision of the policy or are you required to see your doctor 4 times a month. Case workers use provisions like this to their advantage as they are subject to interpretation. Your insurer may rely on the provision and deny your claim stating you are not under “active and ongoing care”.
There are several other provisions within disability policies that operate the same way.
Case workers are not supposed to make medical recommendations to you, but the policies are created in such a way to allow them to circumvent formal medical opinions and do it by way of approving or denying your disability claim.
Understanding the duty to mitigate disability claims
If you’ve submitted a claim for disability, you are obligated by a “duty” under Ontario law.
A duty operates to control foreseeable damage. The duty to mitigate includes:
- Reasonably trying to seek medical attention
- Following reasonable medical advice
- Following reasonable treatment recommendations
- Trying to improve your health to re-enter the workplace
The term “reasonable” is used in the “reasonable person” test: a principle the court uses in evaluating whether a claimant’s actions were appropriate or not. Courts have ruled that a duty to mitigate does not have to be perfect.
Courts have acknowledged that:
- Navigating through the disability wheel is difficult
- You may be vulnerable financially and medically
- Not every treatment is appropriate
Do you have to accept medical treatment?
It depends on who is recommending the medical treatment.
You are not required to:
- Follow medical recommendations by your case worker
- Accept medical advice from your case worker
You have a duty to:
- Listen to reasonable recommendations made by your medical practitioners
In short, you have to follow reasonable medical advice from qualified medical practitioners, not insurance case workers.
What happens if you refuse medical treatment?
Refusing medical treatment can have consequences.
Your insurer may:
- Use it against you
- Deny your disability claim
- Argue you failed to mitigate
- Claim you are prolonging your disability by not seeking active and ongoing care
However, you are not required to:
- Exhaust every available avenue of treatment
- Undergo high risk surgery and/or treatment
- Accept care that conflicts with your doctor’s advice
But you do have a duty to consider what the best medical option is.
How to handle insurance pressure?
If your case worker is pressing a medical recommendation upon you:
Best practice:
- Do not agree immediately
- Advise your case worker that you will consult with your doctor first
- Document everything
- Bring the information the case worker is suggesting to your doctor
- Work with your doctor to obtain guidance and the best route forward
You do not need to blindly abide by your case workers’ suggestions especially if they are irrational or unreasonable.
Frequently asked questions
Can an insurance company force you to take treatment?
No. Insurance companies cannot force treatment, but they may deny your claim if you refuse reasonable medical care.
Who should I listen to: my doctor or my insurance case worker?
You should follow your doctor’s medical advice. Case managers are not healthcare professionals.
What does “duty to mitigate” mean in disability claims?
It means you must take reasonable steps to improve your condition, including seeking treatment and following appropriate medical advice from medical practitioners.
Can my disability claim be denied if I refuse treatment?
Yes, but only if the treatment is considered reasonable and low-risk. Refusing high-risk or inappropriate treatment can be justified.
What is “active and ongoing care”?
It is a common insurance policy requirement, but it is often vaguely defined and can be used to challenge claims.
When to speak to a disability lawyer?
You should consider legal advice if:
- You are struggling to communicate with your case worker
- You feel they are scrutinizing your claim into denial
- Your claim is denied
- There is conflict between your doctor and insurer
A disability lawyer can:
- Protect your rights
- Help guide you through next steps
- Communicate with your insurer
- Help you avoid taking any prejudicial action in your disability claim
Conclusion:
You are not obligated to follow medical advice from your insurance company, but you do have a legal duty to act reasonably in managing your health.
The key is understanding the difference between:
- Medical advice (from your doctor)
- Claim decisions (from your insurer)
When in doubt, rely on qualified healthcare professionals and seek legal guidance early. Doing so can protect both your health and your right to disability benefits.
The disability legal team at Whitten & Lublin is equipped to handle all disability insurance issues. If you have concerns about your case worker or are facing an unfair denial of your disability benefits, contact Whitten & Lublin. We offer free consultations for short- and long-term disability denials. Contact us online or call 416 640 2667.
Author – Aman Chaggar
