What happens when the claimant refuses to seek and accept medical care that might enable the claimant to return to work?

Does the claimant have a duty to seek out and accept medical care aimed at returning to work?  YES.

But there are nuances.

Take a look at the recent case of  Metropolitan Life Insurance Company Life v. Cotter,* (Mass. March 15, 2013) (PDF) (Policy’s “Appropriate Care Clause” imposed on claimant the duty to seek out and accept medical care aimed at returning to work; claimant ineligible to receive benefits for failing to accept appropriate care.)

FACTS: James Cotter sought and obtained disability benefits under disability insurance he purchased, and thus was a non-ERISA case. He claimed his anxiety and an Adjustment Disorder rendered him totally disabled. His treater recommended weekly psychotherapy and a review of his medications.  But Cotter refused. Records confirmed Cotter was “not motivated to return to former employment.” An IME confirmed that Cotter should have weekly psychotherapy, with no medications. Met Life commences suit to determine the parties’ right/obligations under the policy.

TRIAL COURT HELD: Cotter was not receiving appropriate care under the terms of the policy, rendering Cotter ineligible for benefits.

SUPREME JUDICIAL COURT of MASSACHUSETTS AFFIRMS:

1. “[A]n appropriate care clause imposes a duty on the insured to seek and accept care appropriate for his or her “disabling condition.” Whether care is “appropriate” turns on the meaning of the clause “the condition causing the disability.” That clause is to be read in light of the insurance policy as a whole, where “total disability” is defined as the insured’s inability to perform “the material and substantial duties” of the occupation in which he or she was engaged at the time the disability began. An objectively reasonable insured. . . would accordingly understand “the condition causing the disability” to mean the condition preventing the insured from returning to his prior occupation. It follows that care is “appropriate for the condition causing the disability” where, to the extent medically and otherwise reasonable, it seeks to ameliorate the condition preventing the insured from returning to his or her prior occupation.” Op. at 6.

2. “Care provisions ‘serve the additional purpose of minimizing the insurer’s loss under the policy in cases in which the insured’s disability can benefit from a physician’s care by encouraging ‘insureds to seek prompt medical treatment for their disabling conditions.’”  Op. at 4.

Congratulations to Joseph Hamilton and David Fine on some nice work…

*Reprinted from Westlaw with permission of Thomson Reuters.  If you wish to check the currency of this case by using KeyCite on Westlaw you may do so by visiting www.westlaw.com.