Has your mental illness disability claim been denied? Are you worried your long-term disability payments are about to be cut-off?
In this article I review the top five reasons why mental illness disability claims are denied and what you can do to avoid a denial, or at least minimize your chances of denial.
As a disability claim lawyer, a large percentage of the cases I handle involve mental illness claims for disability benefits. In fact, mental illness is one of the leading causes of disability in Canada, especially for doctors, lawyers, nurses, business owners and other professionals.
I constantly see the same reasons for why depression, anxiety and other mental illness disability claims are denied or payments are cut-off by insurance companies. My goal with this article is to educate you about the most common (and avoidable) reasons for a disability benefits denial, so you can avoid making these mistakes, and give yourself the best chance of having your claim approved.
Why Mental Illness Disability Claims are Denied: The Big Picture
Before I get into the reasons for why mental illness disability claims are denied, and what you can do about it, it is important to step back and look at the big picture. This will give you the context to understand the unique challenges of mental illness disability claims.
Mental illness represents one of the most common reasons for disability from the workplace. Over the past decade, insurance companies have seen a rise in the number of disability claims for mental illness. The insurance industry has taken measures to manage mental health-related disability claims.
This “management” ranges from excluding mental illness claims completely in some insurance policies to creating specific internal policies and procedures for handling disability claims.
As a general rule, mental illness disability claims will get special treatment by the insurance company. For example, a common tactic is for insurance company to argue your mental illness is the result of a “toxic work environment”, which they then say is not covered by the insurance policy.
In my experience, it is harder to get a mental illness claim approved (as compared to other medical conditions), and when approved, mental illness claims are more likely to be terminated within two years. Again, this is because of the insurance companies desire to control claims costs in the face of increasing numbers of mental illness disability claims.
This all leads back to the fact that mental illness is a treatable condition; however, a positive treatment outcome requires best practices for medical care. It also requires that you be an active participant in the treatment. If the insurance company doesn’t see evidence of best practices of medical care and active engagement by you, then your claim will get denied. Quickly.
Medical records in mental illness disability claims
In my experience, you have to handle your mental illness disability claim in very carefully in order to win disability payments and to avoid your benefits being terminated while you continue to be disabled.
I have worked with many people who have been denied disability benefits for mental illness, even though they are honest and truly disabled from work. In these situations, the insurance company often has legitimate reasons to deny the disability claim…even though the person is honest and legitimately disabled.
Being honest and legitimately disabled is not not enough to win payment of disability benefits. With disability claims for mental illness, insurance companies will judge your case based on the medical records in its possession. If the medical records don’t accurately document the reality of your situation, then the insurance company bases its decision on the impression created by the records, not the actual reality of your situation.
Therefore, with a mental illness disability claim, your primary goal must be to make sure the medical record accurately communicates the reality of your situation.
With all this in mind, let’s turn to the top 5 reasons for why mental illness disability claims are denied.
Top 5 Reasons Why Mental Illness Claims Are Denied — and what you can do
When reading these reasons, keep in mind that they actually build on one another. So you need to address all of the reasons in order to avoid having your claim denied. Finally, these reasons address what I call “legitimate reasons for denial”, as opposed to a bad faith denial by a rogue claims handler. Unfortunately, there times when an insurance company will deny a legitimate disability claim, even when it is well-documented. That is when you need to call a lawyer because they are not acting fairly.
Reason 1: You are not getting regular care from a family doctor
All insurance policies and disability programs require you to get “regular care” from a physician. This means you need to visit a doctor on a regular basis. What is a “regular basis”? That will depend on your type of mental illness and the treatment you are getting.
The key point is that you have to show you want to get better and that you and your doctor are working to make that happen. Or at the very least that you have explored all options for improving your medical condition and function in the workplace.
When it comes to mental illness, getting “regular care” from your doctor usually means you are seeing your doctor on a bi-weekly or monthly basis. In treating mental illness, the best medical practice is often to prescribe medication to you. Normally, medication prescribed to treat mental illness needs to be carefully monitored and tweaked up and down depending on how you respond to the treatment. If a mediation proves ineffective, you may need to go off it and start another. The point is that your treatment needs to be carefully monitored on an ongoing basis.
If you are not seeing your doctor on a regular basis, at least once per month, then you are in trouble. If you go to your doctor on an erratic and unplanned basis, then you are in trouble. The insurance company will have legitimate grounds to deny your claim, regardless if you are otherwise honest and legitimately disabled.
What you can do about it: Don’t miss any appointments with your doctor. Make sure your prescription medications are monitored. Insist that you doctor schedule appointments on a regular basis. This could mean every two weeks or every month.
Reason 2: You are not being treated or seen by a psychiatrist
Psychiatrists are specialists in treating mental illness. If you are claiming to be disabled by mental illness, but haven’t seen a psychiatrist, this is a red flag for the insurance company.
If you don’t need ongoing treatment from a psychiatrist, at the very least you should have a psychiatrist consult on your treatment. If you haven’t seen a psychiatrist, and there is no plan for you to do so, then you are in trouble. The insurance company will say your depression or anxiety can’t be that bad if you aren’t seeing a psychiatrist.
If your mental heath doesn’t improve, then the insurance company will cite the failure to see a psychiatrist as a reason for denial of benefits. The one exception to this is if your family doctor demonstrates that he or she is providing a very high standard of care in management of your mental illness. I can tell you it is rare to see family doctors demonstrate such a high level of care that the insurance company would not see the lack of a psychiatric consultation as a reason for denial.
What you can do about it: Ask your doctor to refer you to a psychiatrist for a consultation. If you are on a wait list to see a psychiatrist, do everything possible to get into the appointment as fast as possible.
Reason 3: You are not attending recommended psychological treatment
A combination of medications and psychological treatment is usually the best practice for treatment of mental illness.
If any of your doctor recommends that you see a psychologist, then you absolutely have to do it, if you want to avoid a denial of disability benefits. Failure to attend recommended treatment with a psychologist, or attending and giving a half hearted effort, will guarantee a denial of your disability claim for mental illness.
It is common for people to give me a hundred different reasons for why they didn’t go for the recommended psychological treatment. Let me be blunt: Excuses don’t matter. You don’t believe it will work? Doesn’t matter. You can’t afford to see private psychologist? Get on the waiting list for treatment from your local hospital or mental health outpatient centre. You don’t want to sign their forms? Ask for reasonable changes to the forms and sign them anyways.
If your goal is to get well again, and to have your disability claim approved, then you absolutely have to attend any recommended psychological treatment (and give 100% effort). If you don’t get psychological treatment, the insurance company will deny your claim, no matter how legitimate you think your excuse is for not getting treatment.
What you can do: Don’t make excuses. Find a way to attend recommended psychological treatment and give 100% effort. If you can’t afford a private psychologist, then get referred to a hospital or clinic outpatient program that will be covered by Medicare.
Reason 4: your doctors and psychologists are providing a poor standard of care
Even if you are attending treatment with your doctors, psychologists and psychiatrists, the insurance company can still legitimately deny your disability claim if the care you are receiving is substandard.
Getting substandard care is mostly out of your control, but if your treatment providers are not following best practices for treatment of your mental illness, then there is a good chance the insurance company will deny your claim.
Insurance companies have their own behind-the-scenes medical advisors who will carefully review the treatment you are getting from doctors, psychiatrists and psychologists. These behind-the-scenes medical reviewers are well-schooled in the best practices for treatment of mental illness. They are experts at pointing out the deficiencies in what your doctors or psychologist is doing.
For example, a common example of poor standard of care is for your doctor to prescribe medication, but then fail to monitor you carefully and make adjustments to the medication. Without careful monitoring and tweaking of medications, your mental health is unlikely to improve.This can lead to a situation where you claim will be denied, even though you are following your doctor’s recommendations and you are taking the medication as prescribed.
What you can do about it: If you have any sense that your doctor is not following best practices, you may want to get a second opinion. This is why having a psychiatrist consult on your care is extremely important. While the expertise of family physicians can vary widely, most psychiatrists will be well-versed in the best practices for treatment of your condition.
Reason 5: your treatment providers are not creating the proper documentation
From the disability benefits provider’s perspective, if something isn’t written in the medical charts and files, then it doesn’t exist.
Your treatment can be of the highest quality and best practices, but if your treatment provider’s haven’t documented it adequately in the medical records , then in the eyes of the insurance company, you have not received that high quality care.
The reality of what is going on with your treatment doesn’t matter. What matters is what is documented in your medical files and records. At the end of the day, the insurance company makes decisions based on the paperwork that is included in their claim file. You can be getting the best care in the world, but if that care has not been recorded and documented properly, then it will not exist in the insurance company’s file. Without “accurate” medical records, there is a strong possibility that your claim will be declined for technical reasons.
What you can do about it: Point this problem out to your doctors. Have them write a narrative report that explains the treatment provided, your response to treatment, how they have changed the treatment based on your response, and the plan going forward.
If you want to maximize your chances of winning disability insurance payments for mental illness, or to prevent your payments from being cut-off, then you need to be under the regular care of a family doctor who is following the best practices for treatment your mental illness.
Ideally, you will also get treatment from a psychiatrist or at least have a psychiatrist consulting on your care. It is crucial that you attend psychological treatment (and give 100% effort), if it is recommended by your doctor or psychiatrist. You should do your own research — from credible sources — on the best practices for medical care for your mental illness, so you can have some idea if your doctors are meeting those best practices.
If your doctors are not meeting best practices, both in terms of treatment and in documenting your treatment, then your benefits will be cut off at some point, even though you continue to be disabled and unable to work.
In some situations, the insurance company will deny your legitimate disability claim, even if you and your doctors can do everything right. If that applies to you, you should seek legal advice immediately. The insurance company is not acting fairly, so engaging in future appeals on your own will likely have little chance of success.
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