Insurance companies are programmed to assume most insureds filing for disability are either faking or exaggerating their inability to sustain work. It is presumed between 15-20 percent of disability applications received are fraudulent and shouldn’t be paid, therefore, the majority of insureds and claimants endure aggressive risk management so that insurers can locate the minority of claims that are submitted fraudulently. But, it’s more than that.
Disability policies contain provisional language limiting benefits to 24 months at the discretion of insurers. This means all disability insurers can deny claims based on internal medical reviews stating claims are “mental and nervous”; the impairment is “somaticized (all in your head); or due to “self-reported” symptoms. All it takes is an insurance internal review stating primary diagnoses are listed in the DSM-IV (or V), or “self-reported.”
Mental and Nervous disorders as defined for disability claims purposes are mental impairments listed in the DSM-IV(V), Diagnostic and Statistical Manual of Mental Disorders. It is my understanding that although CFS and FMS were not listed specifically as mental disorders in the DSM-IV, they are now listed in the DSM-V as “somaticized” mental disorders. This is why insurers are now denying FMS and CFS under the 24-month mental and nervous provisions of the policy.
The word “somatic” means made-up, exaggerated, or “all in your head.” “Conversion disorder” is a good example of a somaticized disorder that can cause epileptic-like seizures, fainting spells, and even paralysis without any direct physical cause. In general, any disorder listed in the DSM-IV except Alzheimer’s and organic brain disease is accepted as qualifying for limited benefits in most STD/LTD policies. LTD policies now refer directly to the DSM-IV as reference to impairments for which limited benefits are paid.
Alleging various impairments are “self-reported” is the area in which most claim abuse occurs. By definition, self-reported impairments are those that cannot be backed up by objective evidence confirming what patients and physicians diagnose is actually true. For example, headaches, pain, depression, and Lyme disease are most often characterized as self-reported.
A “severe headache” for one person may not be for someone else.What is painful to one person might not be painful at all to another. Therefore, while most disability polices DO NOT contain wording requiring the “objective evidence standard”, self-reported provisions require objective evidence through the back door so to speak. (If there is no objective evidence, then it must be self-reported.)
Insurance companies also have the view insureds and claimants can “make-up” or fake bad headaches so they can go out on disability, and exaggerate pain to higher levels for the same reason, or to solicit higher doses of pain medication. Some people are able to continue working with rather high levels of pain, others cannot. As a former claims specialist I can tell you there ARE claimants who DO exaggerate symptoms in order to go out on disability or remain on disability longer.
While most insureds and claimants are honest, there are always those who use the opportunity of disability to stay disabled as long as they possibly can instead of going back to work. Those who are legitimately disabled pay a huge price because of those who abuse the system. It actually takes a very serious impairment to last to age 65 or qualify for SSDI.
Mental and nervous provisions limit insurers’ liability for claims beyond 24 months because of the subjective nature of attempting to verify impairments for which there is no objective proof of existence. Insurers are paranoid about obtaining actual psychotherapy notes in an effort to objectify mental illness, but once obtained information is “snatched’ at the expense of the insured to further limit benefits to even shorter payment periods.
Bottom line? Disability policies pay for mental illness and self-reported claims for limited periods of time. Policies are not intended to pay beyond 24 months for mental and nervous disorders. Although most Individual Disability Income policies (non-ERISA) omit mental and nervous limitations, self-reported disabilities are aggressively risk managed with psychological IMEs, neuropsychological evaluations and patient records requests.
Most insurers presume depression claims with appropriate therapy and medication management should be resolved within 12 months. More serious mental impairments such as Bipolar I&II and Personality disorders are paid for longer periods of time although they, too, are aggressively risk managed.
Those who are legitimately disabled due to mental and nervous conditions should apply immediately for SSDI so that when disability benefits end after 24 months, there is additional income available to support financial needs. It’s not a wise idea to depend on disability insurers to pay claims long-term for mental and nervous or self-reported disabilities. There’s just too much abuse built into the process.
