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"Under Regular & Continuous Care" and "Usual & Customary Treatment"

I alluded to this area of concern earlier. We often see that mental health claims are denied or terminated due to an alleged failure on the part of the claimant to be under the regular and continuous care of a treating physician. In the mental health area, referral to psychiatrists is a significant challenge for claimants, as they often have to wait six or more months for such a referral. Once referred, they are often sent back to their family doctor for further follow-up, only to see the psychiatrist again sporadically. Claims adjudicators and their medical consultants will critique the claimants’ treatment, or lack thereof, as showing inadequate effort to overcome the disability and will fault either the claimant or their treating physician with not pursuing aggressively enough treatment that might so assist an early return to work.

What is the acceptable standard for “regular and continuous care”? If the family doctor can only accommodate an appointment once per month, is that sufficient? Getting independent medical assessments can some times assist in trying to optimize treatment options, however, if such treatment recommendations have no reasonable prospect of being implemented without the availability of necessary resources, how can a complaint be faulted for that? Of course, an IME doesn’t necessarily result in the type of trusted recommendations that a claimant is likely to act upon, unless endorsed by a trusted treating physician. Who knows the claimants better or best? I pose the question not because there is a trite answer to the question, but rather question whether an IME can truly produce an infallible opinion in such cases.

In the area of depression, the treatment choices are connected to the evaluation that is conducted by the health professional, which includes a complete physical examination and medical workup to rule out medical causes. There are illnesses that go hand in hand with depression such as hyperthyroidism and other glandular disturbances, cancer, stroke and heart attack, but of course, depression can appear in the absence of any such underlying medical illnesses. Testing in the absence of a physical medical illness is very difficult, although some psychological tests may be of benefit to provide a baseline1.

1 MDA Duration Guidelines, Presley Reed, M.D. – Depression, Major, 2005-2007 Reed Group, Ltd.