When dealing with the very serious medical condition of depression, the last thing a person wants to worry about is whether or not their disability claim is going to be approved. In the past, insurance companies would accept depression claims, as they thought the few individuals diagnosed with depression would only be on claim for a short while and then return back to work.
As time has progressed, this acceptance is no longer the case. Depression has become a more common diagnosis and resulted in longer, and more expensive, disability claims for the insurance companies. When an individual deals with depression, there are many issues that can arise. It can be difficult to get a clinical diagnosis of depression, as the testing can be more subjective rather than objective, such as for paranoid schizophrenia or seizure disorders.
Insurance companies have revamped their coverages and policies towards mental and nervous claims, including depression. Newer DI policies and almost all group STD/LTD policies now have clauses limiting such claims to 24 months of benefits. If you were filing a depression claim and had an older policy that did not include these limitations, insurance companies would sometimes try to “buy back the policy” and get you to agree to a settlement to close your claim and cancel the policy. This would allow the company to escape any future larger liabilities based on the generous policy language. I would like to provide five tips that will help you avoid pitfalls and benefit denial in your depression insurance claim.
1. If a physical condition caused depression, use it as the basis for the claim.
As mentioned above, mental and nervous disability claims often have a separate 24 month limitation on the length of time benefits will be paid. Often, such medical conditions can be the result of a physical trauma or underlying condition. If you experience chronic pain or have other contributing physical conditions, using these as a basis for your disability claim will help you in a couple of ways. First, you are no longer subject to the 24 month limitation. If your disability extends longer, you are able to continue to receive benefits. Second, some physical conditions may be diagnosed more conclusively and provide stronger, easier proof of your disability for the claims examiner to accept.
2. Obtain medical advice and treatment as soon as possible.
As anyone who has experienced depression knows, it is usually not a sudden-onset condition, although there may be a “triggering event.” Depression sets in over time and is usually not diagnosed until the individual is severely impaired. When a “triggering event” occurs, whether it be the death of a loved one or an automobile accident, see a doctor as soon as any feelings of depression set in. Insurance companies often like to put the cart before the horse in this scenario. For example, a salesman cannot perform his job because he is depressed. If he files his disability claim after he stopped selling because of his depression but did not get diagnosed until later, the insurance company may assert that his poor work resulted in his depression rather than his depression causing his inability to work.
Develop a well documented narrative that shows your work declined as a result of the “triggering event” or a clinically diagnosed depression, and your claim will be approved more quickly with fewer delays.
3. Don’t fall into the trap of the “Shades of Grey” description.
When an individual is experiencing depression, the symptoms are not at their worst every moment of every day. They often appear in fluctuating “shades of grey.” There may be days when you cannot get out of bed and days when you can. As you describe your condition and activities on the claim form, be sure to take the time to be very specific about the duties and activities you can and cannot do along with when and how. A private investigator hired by the insurance company may see you outside your home, while on your claim form you wrote that you couldn’t even go outside. While this difference may due to a simple and logical reason (such as you happened to feel better that day), this issue can be solved by the information reported on the claim form and your doctor’s records.
In addition, providing the best information you can about your symptoms can help your doctor’s diagnosis and treatment plan. Depression affects different people in drastically different ways and can manifest itself in a variety of ways. There are different forms of treatment depending on your symptoms. Being specific and complete will help your doctor prescribe the proper course of treatment and will also enable him or her to provide more complete and clear medical records for the insurance company.
4. If an IME is required, obtain the full IME report.
Independent medical examinations (IME’s) are being demanded less often by insurance companies in mental and nervous disability claims. Some IME reports concluded no evidence of disabling depression, but the IME doctor may have observed other conditions that described the disabling impairments but was not asked to opine on those conditions. The insurance company may just provide a summary or description of the IME’s findings that supports their position rather than the actual underlying report. If an IME is being used by the insurance company in denying your claim, always obtain the full IME report and all of the supporting documents.
5. Be skeptical of settlement offers to prepay and close a claim.
I mentioned that older DI policies have no mental and nervous disability limitation, while most new policies only provide for up to 24 months of benefits over the life of the policy. These older policies generally have very generous language on behalf of the insured and can create large liabilities for insurance companies, especially for mental and nervous claims. This makes these policies very unattractive to claims managers. If you file under an older policy, the insurance company may attempt to settle your claim and pay you benefits for a longer period than you were claiming, as long as you cancel the policy. This may sound fair but may not a good idea. If you try and obtain another policy, it will have the newer, more restrictive provisions. And you may not even be able to obtain disability insurance at all, due to your medical history. In order to obtain an extra five or ten years of benefits, you may be giving up your long term financial security.
The five scenarios presented above are but a few of the claim situations we’ve seen in our offices. Insurance companies are always looking for a way to improve their bottom line and these tactics continue to change and evolve. If you have experienced any of these tactics or have any other stories or experiences you would like to share, please feel free to comment below. Get professional help for yourself when filing a claim, and always remember that your claims examiner works for the insurance company, no matter how nice they may sound.
If you would like for information or a private consultation, please call us at 855.828.4100 or visit us on our website, Royal Claims Advocates. We look forward to assisting you to obtain the benefits you were promised and deserve.