2012 ALUCA TurksLegal Scholarship 2nd Runner Up Essay by Stephanie Catalucci

2012 ALUCA TurksLegal Scholarship

2nd Runner up Mental Illness Claims Stephanie Catalucci | MLC

DSM5 is about to be released and will no doubt redefine or create a raft of new set of diagnostic criteria around illnesses.

What are some special characteristics of claims arising from mental illness and how do you most effectively manage mental illness claims?

Your answer should address the practical issue of day to day claims management including proof of the claim, the role of rehabilitation and the use of third party providers. You may also wish to comment on what (if any) you expect to be the impact of DSM 5 on insurance for disability arising from mental illness.

It started with a claim…

A click of a colleague’s fingers within earshot brings me out of a daze induced by a protracted Income Protection claim where I have reached an impasse. I have been staring blankly at my computer screen for who knows how long. The Claimant is a 48-year-old male suffering from depression and has been on income protection benefits for almost 12 months. Formally the Managing Director of a successful family business, rehabilitation options have been dismissed, independent medical examinations have been undertaken, treating doctors reports have been acquired and…nothing. I am no closer to understanding the potential claim duration, I am no closer to being able to separate the impacts of co-morbidities from the symptoms of the specific condition and I am no closer to ascertaining how treatment is assisting the Claimant in reaching their pre-disability level of function.

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Introduction Mental health has long been a contentious point of discussion within the sphere of insurance and claims and with the impending release of DSM5 it is no surprise that the frontal lobes of those within the industry are working overtime processing the potential benefits and implications that are on the horizon.

The umbrella term of mental illness covers a vast array of complex psychiatric conditions and pursuant to this, when an individual claims one these conditions against their policy, it is almost guaranteed that a unique set of obstacles will follow suit. This essay will address the management of mental health claims, specifically Income Protection claims against retail policies, and the practical issues Claims Consultants encounter in the day-to-day assessment of these types of claims.

Mental Illness Claims - A League Of Their Own Despite numerous and continuous attempts to bring light to mental illness amongst the wider society, it is still something that is seemingly dealt with behind close doors. On the whole, many people are often reluctant to talk openly about mental illness because of the unfavourable connotations that seem to surround it. In assessing mental health claims, Claims Consultants should seek to remain as impartial as possible and assess a claim on its merits. However, we are all susceptible to a pervasive societal bias that exists and consequently, complicates the assessment of mental health claims. This leaves Claimants in a position of being closed off and Claims Consultants in a position of being suspicious.

Mental health claims are essentially subjective in nature, as there is no obvious or tangible way of being able to see how the disability affects an individual from working, like one would with a physical condition. If an individual works as a Carpenter and breaks a leg, that individual being incapacitated from working is a connection easily made. However, if we replace a broken leg with an adjustment disorder, it immediately conjures up a flurry of questions. What? How? Why? To what extent?

As Claims Consultants we are seeking to understand the diagnosis and factors at play contributing to mental illness; how and to what extent the symptoms prevent an individual from performing their occupational duties. Moreover as a claim advances it is important to develop an awareness of how the condition has evolved and continues to render an individual unfit. This, like most things, is easier said than done.

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Even before a mental illness claim manifests into our work queue we are already on the back foot, it is already more complicated than the pancreatic cancer claim, because society, time and time again, questions the legitimacy of mental health issues. Mental illness cries out for exposure and understanding in the public sphere and with everybody weighing in, it is easy to lose sight of a common goal.

From a claims point of view there are very few conditions that will override the complexity faced in managing a mental health claim. Aside from dealing with wider public and personal notions on the topic of mental illness, a Claims Consultant needs to manage a claim where progress cannot be visually measured and conditions can be easily exploited. There is difficulty in trying to determine whether things are going well or if changes should be explored. Mental illness does not show up in an x-ray nor can we order pathology reports. So for Claims Consultants, the notion that we are reliant upon how the Claimant presents and describes their symptoms is nothing short of daunting.

Experience suggests that mental illness claims appeal to our sense of not seeing and not believing. Thereby creating an inherent distrust in Consultants when they are presented with a mental illness claim to assess.

What Is Effective?

With approximately 45% of Australians experiencing a mental health related condition in their lives (ABS: 2008), it is easy to see how mental illness has become the leading cause of disability claims (Super Friend: 2009) and are occupying significant space in the typical claims portfolio. In line with this, Claims Consultants need to adopt techniques to ensure the effective management of claims, otherwise they risk prolonging the life of a claim to unnecessary lengths.

From the outset, Claimants can feel that they may be judged harshly or treated differently because of their claimed condition. This presumption is cultivated through a multitude of platforms we navigate through in our daily lives perpetuating a negative experience around mental health; including but not limited to, the health care system, employers and underwriting methods (IFSA: 2006). Health care professionals are quick to assign mental illness diagnoses without sufficient investigation. Employers are quick to flag your record in the event of stress leave. Underwriters see potential risk in a medical history including mental illness, however severe. Ultimately these experiences place an individual in a position where they feel forced to defend themselves and their condition.

Therein lays the challenge as a Claims Consultant; because in order to successfully manage a mental illness claim, there is a need to develop a relationship of trust and understanding with the Claimant. The sensitive nature of the condition is such that the individual should feel

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safe before they will be open and cooperate with requests. Attitudes towards Claimants battling mental illness should aim to dispel any presuppositions that they themselves have developed about mental illness and the claims process.

As Claims Consultants, we are in contact with people who are at a point in their lives where they are experiening significant personal and financial hardship, and as such our attitude should reflect this throughout the life of the claim. A thoughtful attitude from the beginning sets the tone for claim moving forward.

Similar to that of a newborn baby, a mental illness claim in its infancy is when it is most delicate and requires specific care and attention. It is necessary for the Consultant to draw on the resources available to them as soon as is reasonably feasible. At times an Independent Medical Examination (IME) at claim inception can be very valuable as it confirms, as far as possible, diagnosis, treatment, medication, complicating factors and current and future work capacity.

An IME will set a benchmark you are able to use as a reference point throughout the claim to measure Claimant’s progress or lack thereof.

Due to the complicated nature of mental illness, having as much information as possible from the beginning of the claim allows us to make use of the resources available in the most appropriate way. For instance, awareness that a Claimant has a supportive family and employer may necessitate the use of rehabilitation providers in a way that accommodates a gradual return to work program. Alternatively, if it is apparent that the Claimant has a difficult home life and is unemployed, then it may be appropriate to use a rehabilitation provider to help them with job seeking assistance and reviewing treatment options. Again, the point is, the sooner the details are acquired and on hand, the sooner a plan may be implemented.

The ongoing assessment of a mental illness claim can be arduous and more often than not, it is not going to fit in a nice neat little square. In fact it requires thinking outside the square and being proactive rather than reactive. In an ideal world a Claimant recovers to pre-disability functioning, returns to work successfully and no longer requires claim benefits. While this outcome is favourable it is not common. So where we typically use rehabilitation providers to assist from a vocational perspective we may want to give thought to how we can engage them so the Claimant feels empowered to move beyond their current limitations. It is important for us as Claims Consultants to be a part of their support network as well, which also comes back to necessitating a foundation of trust. All too often with claims we focus on what an individual cannot do and we frequently forget to see what they can. Effectively working with rehabilitation providers can help bridge that gap.

Help Me, Help You The duration management of a mental illness claim should focus on the severity of symptoms, the type of treatment prescribed for the condition, occupational duties and what function is

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reasonably expected given the circumstances.

In mental illness, depending on the diagnosis, the affects can range from mild to severe (OECD:2010).

With such a range in severity it is necessary to understand from a medical perspective the degree to which symptoms are impacting on an individual’s function to work. Further to this, it is particularly pertinent that updated information is gathered regarding the treatment of mental health conditions.

For mental illness, treatment techniques change and evolve over time. Being well informed on current standards allows a Claims Consultant to question and gain insight into what and why certain treatments are or are not being utilised.

Claims Consultants should ensure when gathering medical information, particularly from treating doctors, that they seize the opportunity and obtain relevant information proportionate to the cost, by using targeted questions relevant to the details of the claim. It would be an exercise in futility to request a medical report with generic questions. The greater the understanding about the circumstances of the claim then the more equipped a Claims Consultant is in obtaining the right information for the assessment of the claim. Throughout the duration of a claim, Consultants should be actively involved in information they are requesting and how it relates to the Claimant continuing to meet policy terms and conditions.

Mental health claims can start off looking like a 1000 piece jigsaw puzzle, however, with the right attitude, use of resources and information, it is possible to consolidate all the aspects of the claim.

Moving forward, the introduction of the new diagnostic information in DSM5 may be useful as a reference point in the consideration and acquisition of details relating to the claim.

DSM5: A Double-Edged Sword?

The Diagnostic and Statistical Manual of Mental Disorders (DSM), currently in version IV, is the standard classification of mental disorders used by clinicians and physicians. It is commonly utilised by claims professionals to understand mental health diagnoses. Over past few years this manual has been reviewed and the new release is forthcoming.

The release of DSM5 is looking to be both a blessing and curse for the world of disability claims.

The revised manual will include more specific identifications of conditions, enabling a diagnosis to be broken down. This increased detail around diagnoses will hopefully aid in understanding the severity of conditions and in turn the potential duration of a claim.

Conversely, with more classified conditions, there is likely to be an influx of claim lodgments and the potential for individuals to hang on their diagnosis or label and get stuck in playing a sick role.

In spite the potential spike in claim notifications, it is hoped that DSM5 will assist Claims Consultants

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in assessing the severity of conditions as it encourages diagnoses to be more specific, particularly in relation to treatment, severity and recovery. DSM5 has been noted as incorporating the severity of symptoms in a diagnosis, examining how certain symptoms cross cut several disorders, outlining new assignment techniques to better enable physicians to chart progress and tailoring treatments to individual patients (O’Callaghan: 2010).

Upon its release, Claims Consultants should endeavor to focus on the potential benefits it will bring to claims management. We have all heard the term knowledge and power, and as such if a Claims Consultant is able to understand and question the new diagnostic material in DSM5 then it will allow them to set measurable expectations for Claimants with mental illnesses. Moreover, in some instances the Claimant will be held more accountable for their treatment and recovery.

Closing Thoughts Mental illness claims occupy a large space in the world of disability claims and this will only continue to grow in the future. Mental health is diverse and complex and in order to effectively manage disability claims where they are the focal point, Claims Consultants must focus on their communication techniques, be conscious of their attitude and approach and ensure they have as much information on the circumstances as possible.

DSM5 may have generated some buzz around mental health within the claims world, but when the buzz dissipates the claims will not, subsequently Claims Consultants must learn to be productive with the resources available to them and proactive with their management plans. It is unlikely that mental health claims will decrease in the future, and as such Claims Consultants should continue to develop relationships with Claimants, understand the driving factors at play, set expectations and ask the hard questions. Ultimately, the more effort and time put into a claim the more beneficial the outcome.

Assessing claims requires the appropriate balance between business consideration and Claimant assistance. Consultants are interacting with people at critical times as well as constantly making decisions regarding large sums of money. It is a role that requires thought not blind processing, and mental illness claims will test the patience of a Consultant to their limits. If that appears difficult, that is because it is.

It ended with a claim‌ Now, in the case of my 48 year old claimant, well I have some questions relating to his business structure, his treatment (or lack thereof) and his reluctance for rehab to assist with a structured return to work, noting that his doctor has given the all clear for a partial return to pre-disability work. It may also be appropriate to review the Claimant’s compliance with treatment guidelines and discuss the policy implications if he is seen to not be reasonably following medical advice.

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References 1)

2) 3) 4) 5)

Australian Bureau of Statistics 2008 National Survey of Mental Health and Wellbeing: Summary of Results 2007, ABS, Canberra.

IFSA Mental Health Working Group Claims Survey, 2006 Mental Illness Claim Management Guidelines, Super Friend, 2009, Melbourne, Victoria.

Mental Health, Disability and Work, OECD, 2010, Paris Tiffany O’Callaghan, 2010, DSM-5: Hoarding, Binge Eating and Hypersexuality

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