Text adapted from: "Disability and insurance claims in primary care," in Psychiatry in primary care by Ash Bender (CAMH, 2019).
Claim-related questions from insurers
Insurers request medical documentation to determine a person’s eligibility for disability benefits such as loss of earnings and rehabilitation. The information may be requested by a claims adjudicator, who manages terms and costs, and/or the case manager, who oversees the gathering of supporting documentation and rehabilitation.
Typical questions cover the following topics (Dorian & Bender, 2010):
- Cause: Is this a work-related psychological injury?
- Onset: When did the symptoms and impairment first arise?
- Contributing factors: What other factors are contributing to the inability to work?
- Pre-existing conditions: Is there evidence of pre-existing mental health impairment?
- Diagnosis: What is the most fitting DSM diagnosis?
- Capacity: Is the person able to work in any capacity? If yes, what are the limitations and restrictions? If no, what are the reasons?
- Treatment: What is the proposed treatment plan? Who is the treatment provider? How long will the treatment be required?
- Prognosis: When is return to work expected? What is the person’s prognosis for returning to work in his or her previous position or in a modified position?
Documenting cause: is this a work-related psychological injury?
Cause is most important for claims covered by the Workers’ Compensation system or an automobile insurance provider. In these cases, insurers have an obligation to the claimant if the identified impairment is the result of a workplace incident or automobile accident.
For private insurance provided by employers, cause may be of no significance because employers still have an obligation to replace lost wages due to disability.
Causes of mental health disability include:
Workplace injury, leading to:
- Chronic pain
- Cognitive problems
- Personal loss, leading to depression
Due to the potential for financial gain, insurance claims are often treated with a degree of suspicion. Malingering by symptom exaggeration or intentional feigning must also be considered (American Psychiatric Association, 2013).
Malingering may be involved in 10 to 20 per cent of claims. Risk factors and red flags for malingering include:
- Antisocial personality disorder
- Inconsistent symptoms
- Inconsistency between work and home functioning
- Obvious financial gain
Accepted causes, including “stress,” are expanding, but they are not universally recognized. The workplace is typically not accepted as a cause of psychosis, mania or substance use problems or addiction; however, it may be identified as a precipitant or contributor to the disability. An exception would be if the symptoms arose following exposure to a toxin in the workplace, such as second-hand smoke.
Documenting onset: When did the symptoms and impairment first arise?
First onset of symptoms, as documented in clinical records, is often used to determine cause. In general, the onset of symptoms is expected within six months of an identified occupational cause. This highlights the importance of screening for mental health problems during a disability claim of any kind. Failing to recognize symptoms will result in delayed entitlement or denial of access to specialized mental health treatment.
Documenting contributing factors: What other factors are contributing to the inability to work?
Contributing factors are important for recognizing the multi-factorial nature of disability. Minor contributing factors do not usually affect entitlement but should be considered in treatment planning and prognosis. Examples of contributing factors include:
- Financial strain
- Family problems
- Conflict with manager or co-worker
- Concurrent medical problems
Documenting pre-existing conditions: Is there evidence of pre-existing mental health impairment?
If symptoms were pre-existing, it is important to clearly identify onset and degree of work impairment. For example, a person with a major depressive disorder may have had no symptoms or may have had mild symptoms that were successfully treated without impairing the ability to work. In contrast, a person may have been frequently absent from work before becoming totally disabled following a workplace incident. If mental health problems are present, always note symptom severity and degree of work impairment.