The Battle Between Insurance Companies and Mental Illnesses

Mental illness is on the forefront of much medical innovation and research today.  As we continue to better understand and comprehend the human mind and its illnesses, we’re able to more accurately diagnose and treat many different psychiatric conditions that were either misdiagnosed or simply ignored in the past.  Mental illnesses range greatly in length and severity of the conditions, but they can all be debilitating and render the patient unable to work in their or often, any chosen occupation.  If you or someone you know is suffering from a mental illness and has disability insurance through their employer or individually, you should be able to obtain disability benefits through your policy.  However for reasons I’ll discuss below,  insurance companies unfortunately tend to make this difficult and will vigorously try to delay, reduce, and deny your disability claim due to mental or nervous conditions.  Mental illness has a become a prime target for disability insurance companies, and those souls who are simply trying to collect their benefits have to be prepared for a fight.

To understand the mindset of the disability claim department, you first need to understand why mental illness claims are so frustrating to insurers.  For centuries, mental illnesses have been more feared than understood.  The underlying theory of insurance is to mitigate and reduce risks of loss.  As disability insurers write policies, they create and use actuarial models based on how variables (such as investment rates, morbidity rates, benefit periods, etc.) will behave in the future.  These models are then used to determine the premium levels and sales budgets that are needed to produce the financial results expected by the insurance company.  The most important goal for many insurance companies has switched from protecting their customers to protecting their bottom line.  Problems started when business and economic changes occurred that weren’t foreseen in their actuarial models, and the financial results began to fall below their expected levels.  Insurance companies started searching for and changing their business practices to bridge this gap.

Advances in neuroscience, genetics, and psychology accompanying the explosion of new technologies in the late 20th century are enabling scientists to start new research and unlocking new tools for the diagnosis and treatment of many mental illnesses, and these trends will only increase in the future.  It’s helpful to think about our feelings about mental illnesses as being a little like those about cancer:  for eons, cancer has been a scourge of humanity and was the subject of widespread fear and taboos.  Only in the last century has cancer become increasingly understood and effectively treated.  Many say that we’re entering into a similar time for mental illnesses.

Insurance companies have been surprised by and struggled with the numbers of mental illness diagnoses and treatments.  Disability claims were filed and supported by medical professionals that the actuarial models didn’t project.  In turn, insurance companies went back and changed their policy provisions, such as demanding regular care and treatment by a board certified psychiatrist and limiting benefit periods for such claims.  Two items in today’s policies that came directly out of these changes are the far too common 24-month benefit limit and the expanded definitions of self-reported symptoms.  Claim forms for mental and nervous disabilities have also been made more complicated (but not better) and examination tactics more aggressive as insurers search for new ways to reduce or deny claims and protect the bottom line.

These philosophical shifts have been a big part of people’s poor experiences in the disability claim review processes and one of the main reasons for our firm’s success.  Disability insurance companies often try and turn physical claims into mental claims in order to fit them under the reduced and more restrictive policy provisions while trying to deny mental illness claims by hiring physicians to review medical records and dispute the claimant’s diagnosis.  There are several areas that deserve greater focus when preparing a successful disability claim due to mental illness.  Following these guidelines will hopefully make these claims for benefits significantly easier for the claimant and treating professionals:

  • Maintain thorough and detailed medical records, including notes.  The basis for approval or denial of most disability benefit claims stems from the medical information provided.  Make sure the records are in fact in the claim file and reflect a consistent and ongoing schedule of treatment.  Make sure the insurance company considers the treatment plan to be “appropriate care” according to their policies.  (More on the definitions of appropriate care here.)  Highlight the results of any testing and inventories that support the diagnosis as well as any changes.  Claimants should work with their treating professionals to include as much relevant detail as practical.  Therapy notes should be complete and as specific and descriptive as possible.  It may also be a good idea for patients to develop a medical history document, both for their own reference, for the treating professionals, and for the claim file.  For example, someone who is suffering from a bipolar disorder should make sure that the records show clear periods of both depression and mania that affect not only occupational duties but also social and daily living activities.  Disability claims often need more of these types of supporting details than many practitioners are used to documenting.  Different professionals may be involved in the treatment of bipolar and should each be noted and included.  The more evidence in the records and notes, the better for the disability claim.  This is critical for physicians and therapists to understand and support their patients.
  • Keep a record of all of the usual activities the patient is not able to do.  As patients go about their daily activities, it’s a good idea to note the activities their illnesses are preventing them from successfully completing.  For example, if you are experiencing chronic depression and could not go to the grocery store, make sure this is noted somewhere, somehow.  Surveillance is a common investigative technique in mental illness claims, and those who overstate their restrictions and limitations run the risk of having to justify and explain any obvious inconsistencies.  When you are interviewed by a claims examiner or field representative, some of the questions will relate to activities that are no longer able to be performed.  When people are suffering from mental disabilities, these specific details can be difficult to recall or even document in treatment notes.  Many claimants can also be prone to giving vague or winding answers that can be interpreted for or against their disability.  Having clear examples of tasks that cannot be performed allows both the claimant and the attending physicians to confidently answer these questions and prevent the insurance company from using assumptions or misinterpretations to deny the claim.
  • Take any and all medications prescribed by your treating physician(s).  Our firm has seen too many claimants who can’t or don’t want to deal with the side effects of some medications and may not take their prescriptions.  However, if a patient doesn’t follow the medical advice and doesn’t take the medications as prescribed for his or her condition, the insurance company may be given a basis to refuse to pay the benefits due the lack of appropriate care and treatment.  Taking the medications and keeping good records of the side effects can also help claimants remain clear-headed to deal with the hassles of the insurance company questions and correspondence as well as more actively participate in finding the best treatments and outcomes.
  • Communicate with the insurance company on your terms.  Insurance companies have developed methods to defend against mental and nervous claims and guide the claims adjudication process towards a presupposed outcome.  Claims examiners often prefer to talk on the phone and are taught how to get information that can be used to handle the claim.  You often won’t have a chance to prepare any information or answers.  This tactic is especially effective with claimants who may be experiencing cognitive defects or mental illnesses since their ability to think quickly and coherently is usually compromised.  These conversations provide examiners with opportunities to confuse issues and cause claimants (or more importantly, medical professionals) to inadvertently give answers that can be turned to become beneficial to the insurance company and detrimental to the disability claim.  The confusing and incomplete nature of many claim forms also appears to be designed purposefully, despite the understanding that many claimants aren’t in the appropriate mental state to fill out forms and answer questions.  Medical professionals seldom have the time or experience to provide what the claimant needs to prepare a strong disability claim.

Obviously, this is not an all-encompassing list of everything needed to get a disability claim approved.  There are many other steps that claimants and their medical providers can take to protect themselves against the tactics of disability insurance companies and their claims examiners.  However, considering these guidelines is a good start down the path towards approval of a valid disability claim.  Mental illness claims are highly scrutinized and developing not only a treatment plan but also a strategy for a disability claim appropriate to the claimant’s circumstances is a great idea.  Preparing for how to file and support your disability claim can mean the difference between getting the benefits you deserve quickly and simply or having to struggle with a long, stressful, and risky process.

If you have questions specific to your claim or about anything in this article, please call our offices at (855) 828-4100 or sign up for a free consultation on our website.

One thought on “The Battle Between Insurance Companies and Mental Illnesses

  1. Pingback: 6 Potential Pitfalls of Your Chronic Back Pain Disability Claim | Royal Claims Advocates

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