Psychological and psychiatric based long term disability claims are heavily scrutinized by long term disability insurance companies. Add the COVID-19 devastation to that equation and claims will be harder to get approved and stay approved. Mental and nervous disability claims are already on the rise due to COVID-19; and the insurance company toolbox to delay, deny and terminate these claims already exists and is well-stocked. Here are some tips and advice for you to best prepare yourself.
Do You Have Coverage?
The first step is to know what type of coverage you have for mental and nervous disabilities. Some individual long term disability policies have coverage for these claims for as long as you are disabled. Some limit the benefit period to a few years, and some exclude it entirely. Employer-sponsored group policies typically limit the duration of these types of claims, mostly to two years. Know what coverage you have to start.
Thinking About Filing a Claim and Are New to Mental Health Care
If you are considering whether to file a long term disability claim for a mental and nervous condition but are new to treating with mental health professionals, here are a few pointers.
First, you should consult and treat with a licensed healthcare professional, preferably a psychiatrist or licensed psychologist. While your primary care physician can diagnose and prescribe medication to treat a mental health condition, long term disability insurance companies typically will not accept that doctor alone to support your mental and nervous long term disability claim. Even if they accept your primary care physician on an initial basis, you are likely to run into problems keeping the claim support by your primary care doctor.
Next, your mental health treating professionals will need to make a diagnosis, a plan of care, and support your inability to work in your own occupation, or any occupation, depending on the policy(s) requirements to obtain benefits. For many mental and nervous conditions, the insurance companies expect your plan of care to include medication and counseling. In cases where a claimant is not receiving both medication and counseling, your long term disability insurance company may argue you are not receiving care that is appropriate to manage/improve your disability, giving the company an argument that benefits need not be paid. Many of our clients disabled from mental and nervous conditions receiving their medication from a licensed physician, and get their counseling from a psychologist, psychotherapist, or other, non-physician mental health counselor.
Finally, don’t go see a doctor once and expect to make a successful long term disability claim. While that is possible, your condition is likely to require a number of visits, and your mental health treating professionals are unlikely to support your claim after only one visit. A course of treatment and evaluation over 3-6 months is likely to be sufficient. Each situation is, of course, different when it comes to mental health, but 3-6 months is a good rule of thumb. Making a decision to stop work and file a long term disability claim is frightening and involves a bit of a leap of faith. If your doctor(s) are supportive and on board, however, the decision will be much less stressful and you will be much more likely to succeed.
Thinking About Filing a Claim with a History of Mental Health Care Treatment
If you already were seeing mental health care professionals and treating for a mental and nervous condition, your long term disability insurance company is going to ask what has changed in your condition such that you have now stopped work and seek benefits.
Here and some examples to help you document deterioration in your condition and the need to stop work and file a claim.
- More frequent therapy sessions;
- Trying different medication regimen;
- The mental health professional’s notes will detail increased tearfulness, arrests, threat of self-harm, failure to maintain hygiene, social isolation, increased marital discord of family tension;
- Increased physical symptoms such as rashes, shaking, sweating, hair loss (pulling it out), scratching;
- Cognitive changes such as the inability to organize thoughts or maintain a coherent conversation;
- Search for medical reasons for your mental health issues e.g., MRI for MS or other organic brain dysfunction, consultation with an Alzheimer’s Specialist;
- Downward Trend on the Global Assessment of Functioning, your GAF Score. Although the Global Assessment of Functioning tool is no longer officially in use, mental health professionals and insurance companies alike still use it as a quasi-objective snapshot of an insured’s mental state. The GAF scale is explained below:
GLOBAL ASSESSMENT FUNCTIONING SCALE (“GAF”)
- 91 – 100 No symptoms. Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. [Note that this range is not included in some versions of the GAF].
- 81 – 90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns.
- 71 – 80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).
- 61 – 70 Some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.
- 51 – 60 Moderate symptoms (e.g., flat affect and circumlocutory speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).
- 41 – 50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job, cannot work).
- 31 – 40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed adult avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school).
- 21 – 30 Behavior is considerably influenced by delusions or hallucinations or serious impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends).
- 11 – 20 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute).
- 1 – 10 Persistent danger of severely hurting self or others (e.g., recurrent violence) or persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death.
Mental Health Claims Already Being Paid
If you are on claim and being paid by a long term disability insurance company, make sure you are keeping up with the frequency of health care professional appointments and filling your prescriptions, if you are taking medication. Phone and video chat have become an integral part of health care, including mental health care, particularly in light of COVID-19. Take advantage of it.
Also, as helpful as a mental healthcare professional’s notes can be, they can also be a minefield. For example, they may note a patient’s tendency to prevaricate or exaggerate, or they may note job dissatisfaction and lack of interest in pursuing work, which are all factors that would lead to an insurance company to increase its scrutiny of, deny, or terminate a long term disability claim.
Finally, beware of disabling conditions that your long term insurance company may treat as those which should be of limited duration. For example, bereavement issues, loved one illness issues, and divorce or marital discord are all types of issues where your long term disability insurance company will expect you to recover and return to work. This is when it is essential for you to convey the details of your ongoing symptoms and difficulties to your health care professionals, and that they continue to document and support your claim.
If you’re considering whether the mental and nervous condition(s) may entitle you to long term disability benefits, are considering filing a claim, or are having problems with your long term disability insurance company, don’t hesitate to give us a call.
Evan S. Schwartz
Founder of Schwartz, Conroy & Hack