Our understanding and treatment of HIV/AIDS has changed dramatically since it appeared in the public consciousness in the 1980’s. In its early stages, health providers and insurance companies often considered HIV/AIDS a terminal disease, but continuing advances in medications and treatments have changed the outlook to a chronic condition. In fact, the life expectancy for many patients in treatment continues to increase and is returning to the level of the overall population. But the disease as well as some treatments can still cause complications that make it impossible for people to continue working in their own occupations or otherwise. While a thorough study of this topic could fill volumes of books and still not be complete, I want to briefly touch on how the advances in treatment and the changes in popular belief on HIV/AIDS affect those who are trying to obtain their disability benefits.
Both the Social Security Administration and many insurance companies considered HIV/AIDS to be a terminal disease through the early 2000’s. This definition began to change as the HAART (highly active antiretroviral therapy) treatment, commonly known as the “AIDS cocktail,” became the prevalent course of action. A combination of at least three antiretroviral medications, the HAART treatment causes far fewer long-term and short-term side effects than previous treatments. This improvement has caused a change in the way disability claims resulting from an HIV/AIDS diagnosis were processed. Previously, these claims were readily approved as the insureds had high mortality rates, and the duration and amount of benefits was not expected to be very high. With more accurate classifications of disability claims from HIV as more of a chronic condition as opposed to those resulting from an AIDS diagnosis, claims resulting from HIV are beginning to receive much more scrutiny from insurance companies.
The longer an insured is disabled or expected to be out of work, the greater liability the disability claim is to the insurer. As the life expectancy increases for these individuals, so does the amount of reserves insurance companies have to set aside to pay for the expected claims. This has caused companies to invest more resources to aggressively investigate these claims. Techniques that HIV diagnosed insureds had not previously seen, such as occupational analysis, surveillance, and independent medical evaluations (IME’s), have now become more prevalent along an increase in claim denials. In light of such developments, it is important to understand the regulations surrounding these claims. There are three categories of reasons that may qualify an insured to collect disability benefits because of HIV/AIDS: the disease itself, opportunistic infections, and symptoms or complications of treatment.
Insureds with HIV/AIDS who participate in occupations that may present physical causes for exposure to bodily fluids, such as doctors, nurses, and dentists, are hard pressed to be able to continue to practice their professions out of safety risks to their patients. On the other hand, HIV may not present the same level of risks in another occupation, such as a law office receptionist. It’s critical to make sure that the attending physician is using a complete, accurate, and thorough description of the duties involved in an insured’s job so that those duties impacted by the disability are clearly identified.
Of course, it’s also imperative to consider the types of “occupation” in a specific policy to help determine whether or not an insured qualifies for disability benefits. If an insured has an “own-occ” policy and can no longer perform the material and substantial duties of his or her occupation in a similar manner, the disability insurance would be expected to extend coverage and benefits resulting from an HIV diagnosis. However, if the policy has an “any-occ” or “modified own-occ” definition, the policy may not cover an HIV diagnosis so clearly, and the insured may even be faced with having to find a job for which his or her HIV status would not be preclusion to the job’s duties and responsibilities.
Often it is not HIV that causes an insured to file a disability claim, but rather it is the opportunistic infections. Insurance companies sometimes do not fully understand the scope of the complications that can arise from HIV and its treatments. Like many other chronic conditions, insureds with HIV must vigorously protect their rights and ensure that the disability insurers are not making assumptions and overstepping their boundaries when investigating the claim. It is important for the attending physician to provide proof of the opportunistic infection(s) as well as describe the symptoms and functional limitations caused by the infections, not just of the HIV condition alone.
While an HIV diagnosis in and of itself may not qualify every insured to collect disability benefits, there are other side effects and conditions that may result in a successful disability claim. HAART has been found to be safer and more effective than many previous HIV/AIDS treatments, but that still does not mean that it is perfect unfortunately. Some potential side effects and complications include arrhythmia, bone death, osteoporosis, liver damage, hyperglycemia, and nausea. Any of these symptoms may become so severe and persistent that an insured is prevented from continuing their occupation or even pursuing any other occupation. If this has become the case, an insured needs to make sure their attending physician includes detailed medical records clearly addressing the treatments as well as the cause and extent of the symptoms and side effects. If more space is needed than the 2 or 3 narrow lines or 1 small box provided on the claim form, take as much space as is needed by attaching pages and referencing the attached pages on the claim form. Insurance companies have been known to try to assert that an insured is not, or is no longer, disabled because their disease is in treatment or remission. Of course, HIV can never be in remission, by definition. And the treatment of the disease may be a significant contributing cause as to what is keeping the insured from working. This must be clearly and convincingly communicated to the insurance company.
HIV/AIDS is a condition that has become better understood and more effectively treated. We all hope and pray that these improvements continue and increase and someday won’t even be the basis for anything worse than a perhaps a few sick days off from work. These advances in treatments and the improved health of HIV patients is great news, but ironically, those advances have made it much more difficult and complicated for those insureds to successfully claim disability benefits when they are truly needed. It almost seems like insurance companies punish individuals for obtaining treatment that increases their quality of life! If you have HIV/AIDS and good or bad experiences with your disability insurer, please feel free to tell your story in the comment section below. If you have any questions or would like to obtain more information, please visit our website for disability claim advice.