Insurer contacting my doctor inappropriately


The purpose of this post is to see if the manner in which my insurer has communicated with my doctor is improper. (In particular, my LTD contract states that the insurer “will in no way disturb the Physician/patient relationship.”)

I recently had my doctor fill out the annual Physician’s Form and I returned it to my insurer. A few weeks after returning the Physician’s Form I found out that upon receipt of the form the insurer had contacted my doctor for more information.

However Instead of asking for my medical file, the insurer had started to engage my doctor in medical a conversation. In particular, the insurer had started to discuss, (by commenting in writing), the contents of the Physician’s Form as filled by my doctor, writing to him how particular sections of the filled form were not supporting the limitations that my doctor had listed, and communicating to how the form was not sufficient to establish disability.

While writing to my doctor the insurer also provided him, (in writing), a wrong definition of disability, stating that according to what my doctor had written in the form, I do not have a total functionality loss to support an inability to return to work. (This is an incorrect definition of disability because I only have to be unable to perform and maintain in an occupation similar to my previous one, and consistent with my training, skills, work experience.)

Then, instead of asking for my medical file the insurer started to ask for “specific clinical exams and diagnostic findings” to support disability! They did not stop at asking once, but keep at asking it a couple more times. Finally, after the third such request, my doctor, frustrated by these repeated requests, wrote to my insurer that he has referred me to a specialist. (I actually do not mind this, however, I feel that the insurer should not influence my doctor’s choices, since once this occurs, what stops the insurer from doing it again in the future!?)

I should note that In the process of making all of these requests, the insurer had failed to provide any written disclosure authorization, despite that i had signed one and gave it to my insurer.

Is any of this behavior amounting to breach of contract? My contract states that insurer "will in no way disturb the Physician/patient relationship. " Are there any actions I should take?

Regards, Alecs

(Note: I have tried to make this post as anonymous as possible, however, I am not too concerned about the insurer reading this, since I already protested in regard to these actions.)

I’m pretty sure my insurer always cc’d me on any requests for information that they sent to my doctors. It sounds like they didn’t do this in your case.

Also, the insurer is likely prepared to cut you off without more information so it is probably in your best interest to let the insurer get that information. They are allowed to ask for clarification and more information.

I’m sorry that I can’t answer your question about breach of contract.

Good luck.

Hi Aleca

Of course I am not a lawyer but in the past, I have had my insurance company misread or take medical info out of context (sometimes the report is not that clear and can be misinterpreted) or it has not been clear in terms of how it has impacted you daily living. What helped me was having one of my Specialist (with extensive experience dealing with insurance claims) agree to write a summary letter of the history of my medical condition and an updated report of my past and current functioning based on all my medical info. (That is a lot to ask and not always easy to find someone to do that) Although the insurance company has access to your medical file they don’t always access that info re: time lines but instead rely on the Docs recent reports. The trouble here is that many Docs do not speak in terms of “functionality” - Occupational Therapist do (they are trained to look at how injury or illness impacts all aspects of daily living) No offence to physicians because there is always exceptions but they may require respectful guidance to complete these forms or answer the questions in terms of “functional performance”. Maybe you have done this but you stating to your Family Physician (or specialist) in a concise report, specific impairments impacting your daily living/work as a result of your injury can sometimes help - may be too late if your Doc has sent in info. For example, CPP applications ask for this and have check lists in this regard and even that sometimes has to be elaborated on but can help guide what info is required. Also sending your Doc detailed info regarding the demands expected of you in your job and reasons why you can’t perform your work - specific functional performance issues may also help. You do want the Insurance company to get enough medical info as possible that pertains to your functioning. Another example, saying you had a heart attack may not be enough to suggest you can’t perform your job - it is how it is impacting your daily functioning and at work. Not sure if this answers your question. Good luck with this concern.

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