Why Won’t My Doctor Help
With My Disability Insurance Claim?
We frequently discuss how important it is for your treating doctor to support your disability insurance claim. Oftentimes, though, doctors are reluctant to help with the process. Understanding why your provider is hesitant to get involved can better equip you to enlist his or her support.
In our experience, these are the most common reasons why treatment providers decline to assist with disability insurance claims:
They don’t have time. Doctors have extremely busy schedules. Often, they’re concerned that they simply don’t have enough time to properly complete all of the insurance company’s required forms or to answer questions from your claims adjuster.
They are worried about the insurance company harassing them. Many healthcare providers know how complex and combative disability insurance claims can be. Sometimes, providers don’t want to get involved with a claim at all, because they’ve heard of (or experienced) claims personnel harassing treating doctors. This can be a legitimate concern, as left unchecked, insurance companies will often bother treating doctors with repetitive requests for information, pushy phone calls, or by second-guessing the doctors’ treatment plan.
They are worried about doing something to hurt your claim. On the other hand, many providers aren’t familiar with the private disability insurance claims process at all. This sometimes makes providers hesitant to complete Attending Physician’s Statements or to discuss your claim with an adjuster for fear that they will inadvertently say something that prejudices you.
They don’t know the definition of disability in your policy. Not every treatment provider is familiar with the type of own-occupation policy that many physicians, dentists, and other professionals purchase. When some providers hear the word “disability,” they think of a state of total helplessness, or of the much more stringent Social Security definition of “disability.” If a provider doesn’t know that your policy deems you “disabled” if your condition prevents you from performing the duties of your own job, he or she might think you don’t qualify for disability benefits.
Continue reading “Why Won’t My Doctor Help
With My Disability Insurance Claim?”
Beware the “Offset”
Insureds may think that if their disability claim is approved and the insurer begins paying disability benefits, they have won the battle. In reality, however, even the insurer’s complete admission that the insured is disabled within the terms of the policy does not mean that the insurer will pay the full monthly benefit listed in the policy. Most of us think of disability insurance as providing a stream of income to replace lost salary, but few understand that these policies often contain language effectively cutting off other benefits to which the insured would otherwise be entitled.
Disability insurance policies, especially long-term disability policies, frequently contain “offset” provisions, which offset other benefits against the insurer’s monthly payments. Common offsets include benefits which the insured receives from Social Security disability or retirement, unemployment compensation, worker’s compensation, no-fault auto insurance, sick leave, severance pay, and others. The net effect of these offsets is that should the insured receive a benefit from another source, the disability insurance company will reduce its monthly payment by the same amount.
How Can I Keep My Disability Insurance Company From Contacting My Doctors Without My Consent?
In our recent post, “Should Disability Insurance Companies Be Deciding What Kind of Care You Receive?” we explained that insurance companies will often contact your treatment providers directly without your consent, ambushing them with medical studies and demanding answers to a plethora of questions about your medical treatment in an effort to undermine your disability claim. In many instances, insurance companies will refuse to produce the medical reports their in-house doctors wrote about you, but still expect full access to your treatment providers and their reports.
If this happens to you, you may (justifiably) feel like the insurance company is going behind your back and unfairly manipulating the disability claims process. Your treatment providers may become upset because the insurance company is harassing them to respond to detailed questions without adequate time to understand the questions and/or provide thorough answers. You may even notice your doctors acting differently towards you after speaking with the insurance company. For example, your doctor might begin to avoid you when you ask him or her to provide you with documentation to support your disability claim.
How can you protect your treatment providers from being ambushed by insurance companies and protect your claim from being manipulated?
How Functional Capacity Evaluations Impact
Your Disability Insurance Claim
Our last post discussed what to expect during a functional capacity evaluation (“FCE”), as well as the intended purpose of an FCE. Though FCEs can be a useful tool for measuring your abilities, FCEs do not always provide results that are truly indicative of your ability to do your job on a regular, consistent basis. Many courts have recognized the weaknesses and limitations of FCEs in the disability insurance claim context.
Weaknesses and Limitations of FCEs
There are approximately 10 different types of FCEs, each with its own program, measurement methods, and possible evaluative outcomes. Because FCEs can be influenced by many factors, such as physical ability, beliefs, and perceptions, FCEs need to “be interpreted within the subject’s broad personal and environmental context.”[1] Thus, the FCE “process and its administration are only as good as the examiner.”[2]
Disability insurers often stop paying benefits based on FCE results, even when you can’t actually meet the demands of your former job duties on a consistent basis. This is due to an inherent limitation of FCE testing: the FCE can only measure your capacity to do a certain task for a limited amount of time on a certain day. For instance, you may be able to push and pull ten pounds for a few minutes during the FCE, but that doesn’t mean you can do the same task all day, every day.
Another important limitation of FCE testing is how effort is measured. The FCE examiner normally monitors the subject’s heart rate to determine if he or she is putting forth full effort. If your heart rate isn’t high enough, the examiner will say you didn’t try your hardest, so you can probably do more than you demonstrated during the testing. However, there are factors that affect your effort level that can’t be measured by your heart rate alone. For example, heart rate monitoring doesn’t measure the impact of migraine headaches, kidney failure, or other non-exertional limitations (such as interference with attention and concentration due to pain and fatigue).
Continue reading “How Functional Capacity Evaluations Impact
Your Disability Insurance Claim”
What Is a Functional Capacity Evaluation?
After filing a disability insurance claim, your insurance company may ask you to undergo a Functional Capacity Evaluation, or FCE. The insurer tells you where and when to show up, but you likely have little idea what to expect when you arrive. What is an FCE, what is its purpose, and how will it affect your disability claim?
What Is an FCE?
FCEs are formal examinations performed by occupational therapists (OTs) or physical therapists (PTs), not physicians. The purpose of the FCE, according to your disability insurer, is to evaluate your ability to perform the substantial and material duties of your occupation.
What Can You Expect at the FCE?
FCEs usually last between four to six hours, but depending on the tests your insurer has requested, they could be longer, taking place over two consecutive days.
Continue reading “What Is a Functional Capacity Evaluation?”
What is an Incontestability Clause? An Arizona Case Study
What is an incontestability clause? An incontestability clause protects you against being denied coverage because of a preexisting condition.
This clause precludes insurance carriers from inquiring into the representations dentists, physicians, and other professionals made on the policy application if the two-year incontestable period has lapsed. In essence, the clause gives insurers a two-year time limit to review policy applications. If the insurance company makes no inquiry in those two years, they lose the ability to rescind the policy based on a preexisting condition.
For example in the case of Robison v. Brotherhood of R. R. Trainmen Ins. Dept.,[1] the plaintiff had been treated for tuberculosis prior to the effective date of the policy. Three years after obtaining the policy he became disabled from tuberculosis. When the insurance company tried to deny the insured’s claim, the Arizona Supreme Court ruled from its bench in Phoenix that the incontestable clause of the contract precluded the insurance company from inquiring about the insured’s health prior to the effective date of the policy.[2]
Second, this clause protects you against an insurance company’s attempt to deny a claim for disability insurance benefits based on a representation you made that is not material. For instance, when filling out the application for the insurance policy, you might write down the wrong year that you had some minor knee surgery. An insurance company cannot use such a miniscule and immaterial mistake to deny you coverage when your claim is for debilitating arthritis in your hands which doesn’t allow you to practice properly in your field of medicine.
Third, this clause protects an insured that is completely truthful when filling out the policy paperwork. In Paul Revere Life Ins. Co. v. Haas the court upheld a policy which limited “coverage to sicknesses that ‘first manifest’ themselves after the policy has been issued.”[3] This means that if you have a condition before the insurer issued the policy, but you don’t become aware of it until after the policy has become effective, the condition should be covered.
It is important to remember that and incontestable clause usually includes a caveat: it does not protect an insured that knowingly or fraudulently misrepresents information during the application process. The Haas court stated that the language of the incontestable clause “does not protect insureds who make fraudulent misrepresentations in their applications. Rather, the language is intended to protect those insureds who are unaware of their diseases.”[4] The insurance company in Haas (Paul Revere, a subsidiary of Unum) was allowed to deny coverage of the insured’s eye condition when the insured knew about and had been treated for the disease well before the start of the policy. The court believed that the legislature did not intend for the mandatory incontestable clause to be “an invitation for fraudulent applications for disability insurance.”[5] The preexisting eye condition was deemed to be a fraudulent misrepresentation, and the insurance company denied its coverage. We also discussed this topic in a previous post entitled “Medical History Misstatements On A Disability Insurance Application Can Void The Policy In The Future.”
The outcomes of the cases based on incontestable clauses show how important it is to be truthful throughout the insurance claim process. The more accurate you are about your health condition, the fewer coverage problems you may have down the road.
If you have questions about your policy’s incontestability provisions, an experienced Arizona disability insurance attorney can help talk you through how they work, and how that could impact your disability insurance claim.
[1] Robison v. Brotherhood of R. R. Trainmen Ins. Dept., 73 Ariz. 352, 241 P.2d 791 (1952), opinion modified on reh’g on other grounds, 74 Ariz. 44, 243 P.2d 472 (1952).
[2] Id.
[3] Paul Revere Life Ins. Co. v. Haas, 137 N.J. 190, 210, 644 A.2d 1098, 1108 (1994).
[4] Id.
How Long Do I Have to Formally File My Claim?
You have finally come to the realization that working through the pain and limitations of your disability is no longer in your best interests. Continuing to work is not an option for you, so you have decided to make a long term disability insurance claim. How long do you have to file your claim? Does it have to be on the day that you become disabled, or can it happen a couple months down the road? The answer to that question is: it depends.
Insurance companies will try and exploit every option available to deny a claim for disability insurance benefits. One method they utilize is to put strict requirements on how and when an insured must give notice to the company of their disability and what that notice must contain.
The first place to start looking to determine your insurance company’s requirements is the insurance policy itself. Look through the policy index or headings for a section similar to “Notice of Claim.” This section lets you know how much time is available to file a disability claim with the company. Continue reading “How Long Do I Have to Formally File My Claim?”
ABC News Investigates
CIGNA’s Disability Claims Handling Practices
UPDATE: Since this story was originally posted in 2008, the insurance regulators of Maine and Massachusetts initiated targeted market conduct examinations of CIGNA’s disability claims handling practices. The concerns raised by Maine and Massachusetts prompted the insurance commissioners of Connecticut and Pennsylvania to also open market conduct examinations and for the California Insurance Commissioner to reopen his previous examination of CIGNA. In 2013, the examinations resulted in fines against the CIGNA companies, corrective actions being required in its handling of disability claims, and for CIGNA to reevaluate certain claims that were denied or terminated. Information on the CIGNA Multi-State Regulatory Settlement Agreement can be found here.
ABC News/Good Morning America‘s investigation by Chris Cuomo into CIGNA disability claim denials has uncovered some disturbing stories. In the video above, claimants describe some of the hardships they have been forced to endure due to denials of their claims or unreasonable delays in having their claims paid.
One breast cancer survivor, who eventually was paid on her claim with the assistance of a disability insurance attorney, describes her two-year ordeal with CIGNA as a “daily, eight-hour job just to fulfill the information that CIGNA was requesting.” The tactic of wearing down a disabled claimant with repeated requests for documentation that has already been provided multiple times — thereby deliberately delaying payment of the claim — is called “slow walking” by some in the industry. While CIGNA denies engaging in this practice, many claimants who are already emotionally and physically vulnerable due to their disability will eventually quit pursuing benefits to which they are entitled in this battle of attrition that is widespread in the disability insurance industry. In this situation, it is often necessary for a claimant to retain the services of an attorney, not only to take on legal issues with the insurance company but also to shoulder the burden of the excessive and repetitive requests for documentation.
Other claimants in Chris Cuomo’s GMA piece describe (a) three years of fighting CIGNA for their benefits, all the while sinking deeply into debt and losing everything; (b) being caught between a rock and a hard place when told by an employer that he could not return to work due to his disability, but simultaneously having CIGNA deny disability benefits; (c) purchasing insurance to protect herself and her family, only to have her business destroyed, savings depleted and fighting to keep her family home when benefits were denied or delayed.
Another of the claimants profiled, Ursula Guidry, a young wife and mother with advanced breast cancer, initially had her benefits paid by CIGNA, but after awhile, they terminated her benefits and told her she could return to work full-time. Eventually CIGNA settled the claim with her. She passed away three months later. As her husband says, it is tragic that her last year on earth was spent being in a panic over financial issues and fighting an unethical insurance company instead of enjoying as much time as possible with her husband and children.
CIGNA did not respond to GMA re any of the specific claimants profiled, but their Chief Medical Officer stated they pay 90% of disability claims filed and that the majority of their customers are satisfied.
Medical History Misstatements On A Disability Policy Application Can Void The Policy In The Future
Under Pennsylvania law, as affirmed by the Third Circuit Court of Appeals, insurance companies can legally void a disability insurance policy if the insured has made fraudulent misstatements about their past mental or medical history. This is known as “rescission” and is a common tactic insurance companies use to avoid paying claims. In Sadel v. Berkshire Life Insurance Company of America, 473 Fed.Appx. 152 (2012), pharmacist Michael Sadel (“Sadel”) owned two pharmacies in Philadelphia. In 2002, Sadel underwent treatment with Linda May, a clinical social worker, for abuse of prescription narcotics. Sadel continued treatment, in individual and group therapy sessions, through 2006. In 2005, Sadel purchased disability insurance from Berkshire Life Insurance Company of America (“Berkshire”), whose parent company is Guardian, but did not disclose his past drug use or treatment for various mental or emotional disorders to Berkshire when completing the disability insurance coverage application. This could have been due to an ambiguous question on the application form. For example, if the question had asked if Sadel had been or was under the care of a medical doctor, he may not have understood that this also includes care for mental or emotional disorders.
In January of 2007, Sadel lost several fingers on his left hand during a robbery at one of his pharmacies. When treated for the injury, Sadel admitted his past drug use to emergency room workers so that they would not administer drugs to him that would cause a relapse. In February of 2007, Sadel exercised an option to purchase a Future Increase Option policy with Berkshire, which increased his disability insurance coverage. Sadel returned to work at his two pharmacies, but stopped working after an incident at his pharmacy in June of 2007, in which a customer approached him from behind and said “stick ‘em up.” During the incident Sadel said his life flashed before his eyes and he realized he could no longer work at the pharmacy. Sadel put his pharmacies up for sale, and notified Berkshire, in August of 2007, of his intent to claim disability benefits under his Berkshire disability insurance policies.
After receiving Sadel’s notification, Berkshire sent Sadel several forms to fill out, and obtained Sadel’s emergency room medical records documenting the robbery incident and treatment. Berkshire also received a report and chart prepared by Linda May, where she indicated that she had treated Sadel for narcotics abuse from 2002 through the time he purchased the original disability insurance coverage with Berkshire. In June of 2008, Berkshire notified Sadel that they had found inconsistencies with his medical records and the insurance policies. Berkshire informed Sadel, in November of 2008, that they were still reviewing the validity of his policies.
Sadel filed suit against Berkshire in January of 2009, alleging bad faith and breach of contract, and sought money damage for the unpaid disability income benefits. Berkshire counterclaimed for rescission of his disability insurance policies, alleging that Sadel had made fraudulent statements on his disability insurance coverage applications. Berkshire was able to make this counterclaim because the disability insurance benefits contract specifically stated that the policy could be voided due to fraudulent misstatements during the application process. Berkshire was successful in District Court, and Sadel appealed to the Third Circuit.
Though Sadel tried to justify his application statements by arguing that he was doing well when he filled out the initial disability insurance application, and that his drug abuse was a small matter which he dealt with in a matter of weeks, Sadel did not prevail in his Berkshire disability claim. The Third Circuit Court upheld the Pennsylvania District Court’s ruling that Berkshire had not acted in bad faith. In fact, the Third Circuit agreed with the District Court finding that Sadel had “knowingly provided fraudulent misrepresentation on his disability insurance applications . . . and he [could not] establish bad faith on the grounds that Berkshire lacked a reasonable basis to deny him benefits.”
This Pennsylvania case is important because it shows that inaccurate or fraudulent statements on a long term disability insurance coverage application, though undiscovered at the time of purchasing disability insurance, will likely come to light when the insured tries claim disability insurance benefits under their policy. Thus, for the insured, when in doubt about what to disclose on long term disability insurance application forms, it is better to err on the side of caution and always disclose your medical history. Insurance purchasers should also keep a copy of the application, which is considered part of the disability insurance policy that will be delivered with the final executed policy to the inured. Furthermore, when filing an insurance claim it is important to have a disability insurance attorney review not just the policy, but the application as well, to see if there are potential problems to claiming the benefits of a disability insurance policy.
The Injured Physician: Is Your Work Ethic Hurting You and Your Patients?
Disability insurance attorneys Edward O. Comitz and Patrick T. Stanley recently had their article “The Injured Physician: Is Your Work Ethic Hurting You and Your Patients?” published in the Winter 2013 edition of AzMedicine, the quarterly publication of the Arizona Medical Association.
In the article, Mr. Comitz and Mr. Stanley review some of the unintended consequences, both professional and personal, of a physician continuing to work through adversity, and the potential impact on his or her disability insurance coverage. For example, a physician who has modified his practice or work schedule in an effort to accommodate a disability may effectively change his occupational definition as it is defined in his “own occupation” disability insurance policy, making it difficult, if not impossible, to collect benefits when they are most needed.
The article also analyzes some of the pitfalls of “residual disability” or “partial disability” riders, such as the manner in which the insurer will determine the amount of benefits paid and differences in how long the insurance company is required to pay benefits.
The Arizona Medical Association periodically updates its website with recent editions of AzMedicine, or you may contact our office to obtain a copy of the full article and/or to speak with a disability insurance attorney.
Attorney Ed Comitz Interviewed by The Street re Disability Insurance
Scottsdale attorney Edward O. Comitz was recently consulted by the popular financial website The Street regarding his thoughts on whether it’s a good financial decision to purchase an individual disability insurance policy. Based on the high premiums and his experience as an attorney who specializes in assisting sick or injured claimants with obtaining the individual disability insurance benefits to which they are entitled, Mr. Comitz advised that, with the exception of medical professionals such as dentists and surgeons – for whom even a minor injury can be career-ending – disability insurance is not a good investment unless you are also prepared to incur the costs of hiring an attorney if your claim is denied or terminated.
Disability Insurer MassMutual Opens West Coast Center in Phoenix, Arizona
Disability insurer Massachusetts Mutual Life Insurance Company aka MassMutual Financial Group has for the first time in its 162-year history opened a West Coast business center. The new 60,000 sq. ft. center is located on Black Canyon Highway near the I-17 and Peoria Avenue in Phoenix, Arizona and will employ as many as 400 people. Arizona Governor Jan Brewer and Phoenix Mayor Greg Stanton were among those on hand for the ribbon-cutting ceremony of the facility on October 16, 2013.
MassMutual CEO Roger Crandall told the Arizona Republic that the new Phoenix center will primarily serve customers and policyholders in the Western U.S., allowing for faster expansion and also mitigating operational risks to the company through diversification of the location of its resources and staff. During Superstorm Sandy, we blogged about the temporary shutdown of many of the disability insurance companies located on the East Coast, including MassMutual, Unum Group/UnumProvident, The Hartford, New York Life, and Berkshire Life/Guardian Life. With locations now in Arizona as well as Massachusetts, the company may be able to avoid a situation where its call center and other operations, such as issuance of disability benefit checks, are suspended due to a natural disaster.
MassMutual employs approximately 6,700 persons nationwide, including nearly 3,500 at its Massachusetts headquarters, which is currently in the midst of a major renovation. Roughly 25 employees have been transferred from MassMutual’s headquarters to the Phoenix facility and an additional 70+ employees, who were a part of The Hartford’s Retirement Plans business prior to its $400 million acquisition by MassMutual in September 2012, will become a part of MassMutual’s Phoenix staff. To round out its staff, MassMutual has announced plans to hire an additional 200-250 employees in the Phoenix, Arizona area.
According to the Arizona Republic, MassMutual has approximately 25,000 clients in Arizona and parts of New Mexico holding roughly $4 billion dollars in insurance coverage. While we are hopeful that MassMutual’s Phoenix facility will bring improvements to MassMutual’s disability insurance claims service, we would also advise disability claimants that having an additional 400 MassMutual local employees could also mean increased and potentially intrusive surveillance.
Guardian Life Insurance Offers Student Loan Protection Program
Guardian Life Insurance Company of America, parent company of Berkshire Life Insurance Company of America, recently launched a new program offering medical and dental professionals insurance for student loans in the event of total disability. This program, which can pay up to $2,000 per month in student loan payments is available to those with advanced degrees – including those in the dental and medical industries – and to new and future practitioners for whom this kind of protection can seem quite appealing. Understanding that most graduates will begin practicing with an increasingly heavy debt load, Guardian represented the program as a simple preventative solution – but will this “win-win” policy be there when you need it?
Statistically speaking, 1 in 4 people will suffer a long-term disability during his or her career, and claimants are responsible for proving disability prior to receiving benefits. Because insurance companies are notorious for employing a number of tactics to “disprove” a disability and avoid paying claims (including subjecting claimants to “independent” medical exams, conducting video surveillance, and otherwise causing undue delays), it is critical that you understand your policy before you buy. As Guardian Life Insurance states, only those who are deemed totally disabled will benefit from this new student loan insurance policy. We expect that claims under these policies will be highly scrutinized, just as they would be with a traditional disability insurance claim. Those considering purchasing disability insurance or filing a disability claim should consult with an attorney to ensure they are prepared with the best possible policy in the event of a disability.
Disability Insurance Q&A: How Should Doctors Approach Their Treating Physicians About a Disability Claim?
Question: How should doctors approach their treating physicians about a disability claim?
Answer: Your treating physician’s support can often be critical to getting your claim approved. A hurried, uninterested physician may not have time to devote to your claim. In addition, fully discussing your condition with a professional, compassionate treating physician will help ensure supportive medical records. When to discuss your potential claim with a physician is an important timing issue. Also, when the time comes to speak to the treating physician about the claim, a disabled dentist or doctor should ensure that the treating physician understands the definition of “disability” under the insurance policy, so that he or she can accurately opine as to the inability of the doctor or dentist to work.
Some of our previous blog posts on this important issue are available here and here.
Disability Insurance Q&A: Why Do So Many Doctors’ Claims Get Denied, and How Can a Law Firm Help?
Question: Why do many doctors’ disability claims get denied, and how can a law firm help?
Answer: Doctors’ and dentists’ disability claims can be expensive for insurance companies to accept. The troubled economy and the rising number of disability claims filed by healthcare professionals have led to financial hardship. This strain on resources creates an incentive for insurance companies to deny medical professionals’ claims. Thus, many insurers closely scrutinize the terms of doctors’ and dentists’ policies in order to find ways to deny disability insurance benefits, as the long-term financial benefit to the insurance company is significant.
Our firm has years of experience in cases in which disability benefits have been rescinded based on alleged misrepresentation or non-disclosure in the original policy application. We also have a strong history of prosecuting cases in which benefits have been denied based on the insurance company’s insistence that a dentist’s or doctor’s “subjective claim” doesn’t provide objective evidence of disability.
Further information on our law firm’s services and what you can expect when filing a disability claim is available on our website at this link.
Disability Insurance Q&A: What is the Difference between “Own Occupation” and “Any Occupation” in Disability Insurance?
Question: What is the difference between “own occupation” and “any occupation” in disability insurance?
Answer: Most doctors purchase an “own-occupation” policy, which provides compensation following a disability that prevents the insured from performing his or her particular duties. If an insured doctor or dentist does not have an “own-occupation” policy, he or she must be disabled from performing the duties of any occupation for which he or she is reasonably qualified in order to receive disability benefits.
Some disability insurance policies are a hybrid, providing own-occupation benefits for a limited period of time, and then converting coverage to the “any occupation” standard.
Some of our previous blog posts analyzing some of the potential loopholes that disability insurers will try to apply to an own-occupation policy can be read here and here.
Changes in DSM-5 Could Affect Some Disability Insurance Claims
More than a decade after work began on updating and revising the Diagnostic and Statistical Manual of Mental Disorders, DSM-5 replaced DSM-IV-TR in May 2013. While some of the changes in diagnostic criteria for disabilities such as intellectual developmental and specific learning disorders or the addition of new diagnoses in DSM-5 for disorders such as hoarding and gender dysphoria are unlikely to affect the private disability insurance claim of a doctor or dentist, the changes in the criteria for diagnosing post-traumatic stress disorder or substance-related and addictive disorders and the addition of the diagnoses of social (pragmatic) communication disorder and mild neurocognitive disorder have potential implications in the context of private disability insurance claims. Additionally, the elimination of the Global Assessment of Functioning (GAF) scale, widely used by insurance companies in determining the medical necessity of treatment, is likely to have an effect on some disability insurance claim determinations.
Some of the changes in DSM-5 are outlined below.
Social (Pragmatic) Communication Disorder: This new diagnosis, which cannot be diagnosed unless autism spectrum disorder has been ruled out, is described by the American Psychiatric Association as pertaining to individuals “who have significant problems using verbal and nonverbal communications for social purposes, leading to impairments in their ability to effectively communicate, participate socially, maintain social relationships, or otherwise perform academically or occupationally. . . Symptoms must be present in early childhood even if they are not recognized until later. . .”
Substance-Related and Addictive Disorders: The categories of substance abuse and substance dependence have been combined, and the criteria for a diagnosis have been strengthened. Where DSM-IV required only one symptom for a diagnosis of substance abuse, DSM-5 requires 2-3 symptoms from a list of 11 potential symptoms. Drug craving has been added to the list of symptoms and “problems with law enforcement” has been eliminated due to cultural differences in law enforcement internationally.
Post-Traumatic Stress Disorder: There are a couple of significant changes in the diagnostic criteria for post-traumatic stress disorder (PTSD). The requirement of DSM-IV that the person personally experience or witness the traumatic event has been eliminated and DSM-5 allows for a PTSD diagnosis when the person has learned that the traumatic event occurred to a close family member or friend, or experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (from sources other than media, photos, television or movies, unless work-related). Additionally, the requirement that the person experience “fear, helplessness or horror at the time of the traumatic event” has been deleted.
The criteria has also been changed to require “actual or threatened death, serious injury, or sexual violence.” The previous manual also allowed for “a threat to the physical integrity of self or others” but did not specify sexual violence.
Mild Neurocognitive Disorder: The American Psychiatric Association describes this new disorder in DSM-5 as “an opportunity for early detection and treatment of cognitive decline before patients’ deficits become more pronounced and progress to major neurocognitive disorder (dementia) or other debilitating conditions.” The APA goes on to characterize the disorder as:
Mild neurocognitive disorder goes beyond normal issues of aging. It describes a level of cognitive decline that requires compensatory strategies and accommodations to help maintain independence and perform activities of daily living. To be diagnosed with this disorder, there must be changes that impact cognitive functioning. These symptoms are usually observed by the individual, a close relative or other knowledgeable informant, such as a friend, colleague, or clinician, or they are detected through objective testing.
Global Assessment of Functioning (GAF) Scale: The GAF scale of 1-100, which was a single global assessment combining separate assessments of symptom severity, danger to self or others, and ability to care for oneself and function socially, has been eliminated from DSM-5. In the place of assigning a GAF number, separate assessments of severity and disability are recommended. The World Health Organization Disability Assessment Schedule (WHODAS 2.0) was determined to be the best current measure of disability for routine clinical use by the DSM-5 Disability Study Group.
The changes in DSM-5 are, of course, far more complex and detailed than what we have outlined above, but if you are suffering from a mental disorder and thinking of filing a private disability insurance claim, we recommend that you coordinate with not only your psychiatrist but an attorney before filing your claim with your insurer.
More information related to DSM-5 is available at this link.
Does Your Unum Claims Handler Have a Personal Financial Incentive to Deny or Terminate Your Disability Claim?
The transcript of Unum Group’s May 23, 2013 Annual Shareholder Meeting provides some disturbing insight into what may motivate claims personnel at Unum to deny or terminate a legitimate disability claim.
Unum’s Chief Executive Officer, President and Director, Thomas R. Watjen reported to the shareholders that they had “overwhelmingly approved” an employee cash incentive system based on performance:
The fourth item of business is the approval of our annual incentive plan, which provides employees the opportunity to earn cash incentive awards based primarily on the company’s performance each year. Our company performs well, employees get treated well from a financial standpoint. Our company doesn’t perform well, employees don’t get treated as well. . . . So our shareholders see, as we as directors and managers see, how to run the company successfully by creating an incentive system based on performance. So that has been overwhelmingly approved.
Later in the meeting, Unum’s Chief Financial Officer, Richard P. McKenney, spoke about the performance of Unum’s “closed block of business,” which includes its individual disability policies issued prior to the mid-1990s–the type of policies that Unum no longer sells.
We do have our Closed Block business. These are policies which are written some time ago. We serve those customers equally as well. But the returns in these businesses are lower.
Taken together, the two statements paint a picture of claims personnel handling the closed block of business under pressure to improve the returns, or else they “won’t get treated as well” or receive as sweet an incentive bonus.
We often hear from claimants who are incredulous that their claims have been denied or terminated despite a mountain of evidence of their disability. This may be one explanation, and having an attorney to advocate for you as a claimant can be essential when you have a financially-motivated adjuster reviewing your claim.
The full transcript of the Unum Annual Shareholder Meeting is available at Seeking Alpha.
Protecting Yourself in the IME Process: Get a Copy
This post is the last in our series on tips for undergoing disability insurance Independent Medical Examinations (“IME”). Today’s topic is a step to take after the examination is over:
Get a copy. After the exam, contact your insurer to ask for a copy of the IME report. Most IME doctors have a copy of their report to the disability insurer within two weeks. Your insurer may send a copy of the IME report to your own treating physician and ask for his or her comments on the exam. In that case, the company will require you to request the IME report directly from your own physician.
When you get the report, review it and compare it against your notes and/or recollection. If anything needs to be clarified, discuss it with your disability insurer or attorney. If you received the copy of the IME report from your own physician, talk about it with him or her. An inaccurate or misleading IME report can be dangerous to your claim for disability benefits, so it’s important to address any inconsistencies as best you can.
For more information on dealing with an IME, see our prior posts:
Protecting Yourself in the IME Process
Completing Intake Forms in Advance
Protecting Yourself in the IME Process: Bring a Friend
We have talked about involving a disability insurance attorney in the IME process, understanding what the insurance policy requires, completing intake forms, making lists, and taking notes. Today in our series about tips for Independent Medical Examinations:
Bring a friend. Taking notes is great, but having a witness present is best. That way, you can focus on participating in the examination, and your witness can focus on observing and taking notes. Moral support is an added benefit.
A friend, spouse or partner can be a good witness, especially if he or she is a medical professional. If you have a disability insurance attorney, he or she may also attend with you or send a representative from the law office.
Take note, however, that some insurance companies specifically state that witness are not allowed at IMEs. Normally, this alleged requirement is stated in the letter the insurer sends you to confirm the examination. If you have a disability insurance attorney involved, the attorney can review the letter, the policy and the law and determine whether or not a witness is allowed to attend.
