Most employer sponsored group disability plans, and a very few individual disability insurance policies, limit the payment of disability benefits to 24 months if the disability is caused by a mental/nervous condition such as Fibromyalgia or Generalized Anxiety Disorder.
Typical language includes the following:
Mental Disorders, Substance Abuse and Other Limited Conditions. Payment of LTD Benefits is limited to 24 months during your entire lifetime for a Disability caused or contributed to by any one or more of the following: 1) Mental Disorders; or 2) Substance Abuse. However if you are confined in a Hospital solely because of a Mental Disorder at the end of the 24 months, this limitation will not apply while you are continuously confined. Mental Disorder means any mental, emotional, behavioral, psychological, personality, cognitive, mood or stress-related abnormality, disorder, disturbance, dysfunction or syndrome.
It should be noted that not all policies exclude coverage for substance or alcohol abuse and others do not limit benefits to 24 months when the psychological condition is the result of organic brain disease or other abnormalities. Language with exceptions to the 24 month mental/nervous cap may include: The period of disability is not limited to 24 months for a disability resulting from schizophrenia, bipolar disorder, dementia, organic brain disease, seropositive arthritis, spinal tumors, malignancy, vascular malformations, radiculopathies, myelopathies, traumatic spinal cord necrosis or muscolopathies.
In essence, under most group policies disabilities due to a mental, nervous condition will be paid for a maximum of 24 months; however that 24 month period does not have to continuous or stem from the same claim or medical condition. Additionally, most mental, nervous conditions must be contained within the DSM-IV or Diagnostic and Statistical Manual of Mental Disorders in order to be considered a psychological condition that falls within this limited coverage provision.
Often, an individual’s physical disability or serious illness causes them to become depressed; and thus, the mental, nervous condition is not the primary or only disabling medical condition. Depression is found to occur at a higher rate among people with a serious illnesses, chronic pain or significant physical limitations. As such, their Depression is secondary to their illness or injury. Unfortunately, many disability insurance companies ignore the primary cause of their claimant’s disability and define the claimant’s disability solely as mental/nervous so that they can limit their liability and pay the claim for only 24 months.
Conditions such as Fibromyalgia or Chronic Fatigue Syndrome are often pushed into the mental/nervous category by insurers because Depression is a component of those illnesses and there are no diagnostic tests that can objectively confirm these illnesses. Thus, it is extremely important for a claimant and his/her physician to clearly identify the primary medical condition causing the inability to work and note that depression or anxiety is a result of that primary condition. The medical records should clearly convey that there are two distinct disabilities: physical/medical and psychological. Once an insurer classifies the claimant’s disability as mental/nervous it takes a great deal of time, effort and convincing to get them to change their mind and agree to pay beyond the 24-month limitation period. At DI Law Group we have been very successful at preparing our clients’ claims so that they are properly categorized by the insurance company as well as at convincing the insurance company that their initial determination was incorrect and benefits are payable beyond 24 months.
Where an insured is disabled as the result of a mental/nervous condition such as Depression, Anxiety, or Panic Disorder it is important for them to build a medical record which supports their claim. An individual who treats only with a primary care physician who briefly notes depression in the record and prescribes an antidepressant, most likely, will not be considered Depressed by the insurance company. It is important, at least where possible, that a person treat with a qualified psychiatrist and/or psychologist who documents the seriousness of the insured’s illness and how it affects their ability to function in general and at work.
Because mental/nervous claims can be difficult to verify, insurance companies seek documentation that may not exist or is irrelevant to the claim in an effort to delay or deny paying the claim. For example, the insurance adjuster will insist on seeing the results of psychiatric testing or neuropsychological testing in addition to therapy records and notes. However, there are many times that such tests were not performed because the treating psychiatrist or psychologist was able to determine a diagnosis and plan of treatment without them and/or the cost of the test was prohibitive or not covered by insurance. Additionally, such testing may not be proper or relevant. Insurance carriers also seek information that is intrusive, highly personal and unrelated to the claim. While the treating therapist is required to keep records, fill out claim forms and provide anecdotal information, they are not required to share private conversations that took place during sessions and/or very personal information that is unrelated to the claim or unnecessary to confirm a diagnosis. Another tactic by used by insurance companies to delay or deny the approval of mental/nervous claims is to question why the insured was not hospitalized if the condition was so serious. At DI Law Group, we help our clients (and their medical providers) present the information necessary to substantiate a claim without making them feel that they have divulged extremely private information.
Finally, it is not uncommon for an insurance company to request that the insured attend an “independent” medical examination (IME) at some point during the administration of the claim. Almost all disability policies allow the carrier to make such a request. These IMEs usually involve a one or two-day neuropsychological examination and an exam with a psychiatrist. However, more often than not the insured is sent to a doctor who does not spend most of his time treating patients, but works for insurance companies performing independent medical examinations. Not surprisingly, these insurance friendly doctors often find that the inured is not disabled and can return to work in their own occupation or any occupation. Our firm takes the steps necessary to ensure that these independent medical examinations are as objective and fair as possible.
If you are struggling with a mental/nervous condition or your insurance carrier has wrongly determined that your claim is subject to the 24 month mental/nervous payment cap, call DI Law Group today for a fee consultation. We are happy to answer questions about all disability policies and claims whether your claim is still being reviewed for payment, you are on claim, or your benefits have been terminated. We can be reached toll free at (866) 363-3628 or through our website at www.dilawgroup.com.