‘I couldn’t believe it’ — why disability claims for mental health are often a struggle

05/25/2019

When Dr. Wei-Yi Song filled out the insurance paperwork for a pregnant 28-year-old female patient who, at 34 weeks of gestation, was suffering from depression, he thought her case would be “a slam dunk.”

The woman had a long history of depression so severe it required shock treatment and was clearly unable to perform her job, said Song, who is currently serving as the president of the Canadian Psychiatric Association.

And yet, the insurance company initially rejected the claim.

“I couldn’t believe it,” Song told Global News.

After following up with the insurer and filing additional paperwork, Song was eventually able to get the claim approved, he said. But the case illustrates the challenges that still remain when employees file a workplace disability claim because of a mental health issue, he added.

One in three workplace disability claims in Canada is related to mental illnesses, which also accounts for 70 per cent of total disability costs, according to the Mental Health Commission of Canada.

Insurance companies are, for the most part, keenly aware of the need for mental health-related benefits in the workplace and have become significantly better at handling such claims, according to several sources consulted by Global News. But insurers are also under pressure to keep costs under control and continue to rely on standards and processes that don’t always fit with the realities of mental health illnesses, according to some of the sources.

A doctor’s opinion isn’t always enough

The basic problem with mental illness is that it’s less visible than a physical ailment. When a worker loses a hand due to an accident, it’s hard to dispute that they have developed a disability, said Andrew Monkhouse, a Toronto employment lawyer.

But when dealing with problems like depression or anxiety, the medical evidence is far less straightforward than, say, an MRI or a blood test. And the issue is not just assessing whether someone suffers from a certain disorder but how far they are along the spectrum, according to Monkhouse. The key question is: what extent is the illness interfering with an employee’s ability to do their job?

Monkhouse, and two other lawyers who specialize in disability claims, said the opinion of a general practitioner (GP) isn’t always enough to convince insurers to accept a disability claim. Employees have a much stronger case when they can present a diagnosis from a specialist, but that can prove difficult to do in a country where seeing a psychiatrist can take up to 18 months.

Julie Holden, an HR consultant with 15 years of experience working in the disability insurance industry, offered a different perspective. Insurers usually accept reports from family doctors — as long as there is a referral to a specialist, she said.

“It’s not ideal, but it is acceptable for a claim,” she said.

But GPs, she said, must provide an actual medical diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders, which psychiatrists in North America use for a standard classification of mental disorders.

“I’ve seen things like ‘inability to cope’ — that is not a diagnosis,” she said.

But even a specialist’s diagnosis isn’t always a silver bullet. Nainesh Kotak, a Mississauga, Ont.-based disability and personal injury lawyer, said doctors are sometimes focused on describing symptoms rather than how a certain disorder interferes with a patient’s ability to perform the essential duties of their work. Medical practitioners, he suggested, should work off of the patient’s job description.

The Canadian Life and Health Insurance Association (CLHIA) said in a statement it has worked with the Canadian Medical Association to develop a standard physician questionnaire for mental health-related disability claims.

“The attending physician, typically their general practitioner, can easily complete the form,” it said.

And in an effort to facilitate treatment and potentially speed up employees’ return to work, some insurance carriers have partnered with third parties that provide quicker access to counsellors, psychologists or psychotherapists, Holden said. This can be helpful especially during the months that often pass between when a patient receives a referral to a specialist and their first appointment, she added.

But employees would have to pay out-of-pocket for the services if they don’t have coverage under their standard workplace health benefits, she added.

Is it a medical problem or a workplace issue?

While mental health claims, in general, tend to be more complex, an especially challenging issue arises when someone develops a mental illness because of, say, an abusive boss or bullying at the office.

In these cases, an insurance carrier may take the view that the underlying problem is a workplace issue that should be handled by HR rather than a medical condition, Holden said.

But the line between a workplace and a medical problem is a fine one, said David Share, president of Toronto-based Share Lawyers. If the disorder becomes severe enough, it may follow someone into a new job and different work environment, he said.

Kotak added that, in his experience, a toxic work environment is often simply a trigger of a pre-existing condition.

Even when patients are able to make a successful claim, some doctors worry about sending them back into a toxic work environment.

“Most of the cases I treat are directly related to a workplace issue,” said Camillo Zacchia, a Montreal-based clinical psychologist. “But what can I do as a psychologist about this?”

Insurers are increasingly working with employers to facilitate a healthy return to work for employees in these situations, Holden said. But, she added, “there’s still work to be done.”

Keeping your benefits can be a lot of work

Often, being approved for disability leave is just half the battle. Making sure patients keep their benefits for as long as they need also requires a considerable amount of effort and paperwork, according to Song.

For patients who are expected to make a recovery and return to work, insurance carriers often require physicians to submit updates every month, Song said.

But, he said, “if I’m not seeing them that regularly, it becomes difficult.”

Patient volumes don’t always allow for monthly check-ins, he said. And monthly visits just aren’t necessary because a patient isn’t going to progress that fast, he added.

What happens if you don’t take your medications?

Another issue with keeping patients on benefits is that individuals with mental illness may stop following their doctor’s advice or taking their medications.

Disability policies usually require claimants to pursue treatment and make a sustained effort to get better and eventually go back to their job. That’s often a sensible goal from a medical point of view as well, Song said. Most people benefit from the structure and sense of self-esteem that employment provides, he added.

But patients suffering from mental illnesses like depression or bipolar disorder may, at times, refuse to follow their treatment, which is a manifestation of their condition rather than an exercise of their judgment, he said.

But patients who stop their treatment are in breach of their policy contract, which could cause them to lose their benefits, Share said.

Still, Holden said most insurance case managers have a much better understanding of mental illness today compared to a few years ago.

“They would understand that it’s the actual illness displaying itself,” she said.

Do internal appeals really work?

As with all claims, employees can challenge a decision to reject a request for disability benefits or terminate payouts through an insurer’s internal appeals system.

But, perhaps unsurprisingly, disability lawyers are skeptical of this avenue.

“If individuals continue to appeal within the long-term disability system, they’re playing into the hands of the insurance company,” Monkhouse said.

Holden, though, said that many denial decisions are reversed on appeal, as long as the employee presents new evidence to support her claim.

“In my experience, there is a good process that is set up,” she said, noting that appeals committee are made up of senior staff.

As a last resort, plan members can also appeal any unpaid insurance claims to the OmbudService for Life and Health Insurance, the CLHIA said.

Overall, the disability insurance industry is moving in the right direction on mental health, several sources said.

But in a still imperfect system, many Canadians continue to struggle.

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