Family doctor shortage can impact the ability to prove disability claims

By Tony Poland, LegalMatters Staff • A family doctor’s role in supporting their patients through an insurance claim process cannot be undervalued, says York Region disability insurance lawyer Courtney Mulqueen. 

However, Mulqueen, principal lawyer and CEO, Mulqueen Disability Law Professional Corporation, says the shortage of these practitioners is impacting both patient care and the ability of those hoping to prove their disability claims, whether it is for Canada Pension Plan disability, sick leave, workplace accommodation or long-term disability.

“Without the support of family doctors through the application process and beyond, many people may be unable access benefits to meet their day-to-day living expenses and pay for the treatment necessary for their recovery and, ultimately, their return to work,” she tells LegalMattersCanada.ca. 

According to the College of Family Physicians of Canada, nearly five million Canadians are without a family physician. That has pushed many patients into overcrowded emergency rooms.

ER shift begins with ’40 to 50 to 60 patients in the waiting room’

Edmonton emergency physician Dr. Aisha Mirza tells CBC that when she goes on shift, “there can be 40 to 50 to 60 patients in the waiting room that haven’t been assessed by a physician yet.” 

“Honestly, I’m surprised these days when a patient does have a family doctor,” she says.

Of those Canadians with a family physician, only 18 per cent said they were able to get an appointment in a day or two while 41 per cent reported it usually takes a week or more, according to an Angus Reid survey. 

For people without doctors, the search can be frustrating. Angus Reid reports 35 per cent of Canadians polled have been looking for more than a year while 29 per cent have abandoned the search.

According to one media report, 1.8 million Ontarians do not have their own primary care provider; by 2025 that number could increase to three million.

The Canadian Medical Association (CMA) says family doctors “provide comprehensive patient support, ensuring patients have continuity of care and the help they need to navigate our complex health system.” 

CMA calls on governments to take action

“The lack of access to family doctors is a growing crisis,” CMA past-president Dr. Katharine Smart said earlier this year. “The CMA is calling on governments to partner with family doctors to find solutions, including the creation of a nationwide data framework to better assess and project future family medicine needs across the country and the implementation of a national licensure model to facilitate the mobility of the current workforce between provinces.”

Mulqueen says most disability claim assessments rely heavily on the information provided by family doctors. 

“The family physician typically would be the one who sees the claimant most frequently from a healthcare aspect,” she says. “They order tests and make referrals to specialists for treatment and consultation. They would be the ones coordinating the claimant’s care and treatment throughout the period of disability. 

The family doctor plays a significant role in proving a disability claim,” says Mulqueen.

“They can provide critical information about medical history, diagnoses, symptoms, treatment, functionality and prognosis for recovery and the return to work,” she says. “This information is essential because it is used when claims adjudicators are determining if the claimant satisfies the definition of disability for the benefit sought.”

In cases where someone is suffering from various medical conditions that cause a disability and complicate treatment and recovery, a family doctor’s opinion may prove to be a critical piece in proving an insurance claim, Mulqueen explains. 

‘The family physician has insight into the patient’s overall condition’

“The family physician has insight into the patient’s overall condition and can comment about the difficulty of treating multiple conditions concurrently. For instance, chronic pain and depression,” she says.

At times where a disability is caused by one primary condition, she says a family doctor’s support may not be as consequential. 

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“In those cases, a family doctor may have little to contribute by way of diagnosis, treatment and prognosis,” says Mulqueen. “Rather, a treating specialist and other treatment providers will be able to provide all the support the person needs to prove their claim. 

“This may be true of mental health conditions, where the person sees a psychotherapist, a psychologist and a psychiatrist,” she adds. “A psychiatrist would be able to provide persuasive information with respect to diagnosis and pharmacological treatment. Therapists would be able to provide information about alternative treatments and psychological functioning.”

Without the care of a family doctor, claimants must rely on physicians who don’t know their history, says Mulqueen. 

“While they may be able to provide a diagnosis and make referrals, they would not available to provide ongoing and consistent treatment and records over the longer term,” she says. “That is necessary to prove disability and eligibility for benefits.”

Patients are falling through the cracks

Dr. Allan Grill, chief of family medicine at Markham Stouffville Hospital, tells CP24 that patients are falling through the cracks.

“Every time somebody doesn’t have access to a primary care provider, they end up accessing care somewhere else that is not appropriate, like our emergency department, which becomes very crowded,” he says. “Then people have to wait and it’s an opportunity where people that really need acute care don’t get it in a timely fashion.” 

Mulqueen says many of her clients whose claims have been denied do not have a family doctor and instead rely on an emergency room or busy walk-in clinic. 

“They may see the doctor there once and then never again,” she says. “Sometimes a single visit could result in referrals to appropriate specialists and treatment providers who are then able to fill the gaps in medical information and provide support for benefit claims.”

However, she says what is more likely to happen is that the combination of medical records, provided by emergency room and walk-in clinic doctors, could result in inconsistent reporting and lack of a clear diagnosis. 

“There is a good chance there will be no reporting with respect to prognosis, piecemeal referrals to specialists who may have long waitlists, recommendations for treatment that claimants might not be able to afford or access within a reasonable time, and little or no follow up,” Mulqueen says.

Lack of understanding can lead to a claim’s denial

The lack of “consistent and coordinated care” can delay the claimant’s recovery and result in a claim denial because the insurance provider does not have a clear understanding of the person’s disability and are unable to determine if benefits are warranted, she says. 

“When these claims are denied, people who are already suffering with illness or injury and struggling to recover are now faced with the added financial stress that comes with not being able to work and not having any income,” says Mulqueen. “Depending on the nature and severity of the disability and the person’s vulnerabilities, appealing the denial of benefits may be too overwhelming or too costly.

“Without financial income, they may not be able to afford to pay for their daily living expenses or treatment,” she adds. “Of course, this could result in additional stress and prolong their disability.” 

In the end, without the support of a family doctor, it may be difficult for someone to prove a disability or dispute a denial. 

“In our practice, we encourage clients to seek the care of a family doctor as soon as possible when they are making a claim,” she says. “Often that means contacting the Ontario College of Physicians and Surgeons or speaking to family and friends to find physicians who are accepting new patients.

“But that is not always possible for some people,” Mulqueen adds. “And until the family doctor shortage is addressed, disability claimants will continue to face significant challenges.”