Undoing Mental Benefit Discrimination

There are still plenty of people who don’t believe mental health victims require the same level of treatment as do physical illness victims. Among those in the first row of these skeptics are many insurance companies. After all, if insurance companies can fashion anything that looks like an excuse not to pay benefits, they will do it and use it.

A recent settlement reported between Cigna Corporation and the Attorney-General of New York State made this clear. New York has a law which requires insurance companies to provide mental health benefits on a par with other medical benefits.

A 14-year-old girl found that Cigna ignored that law when she asked for payment of nutritional counseling fees she incurred for treatment of anorexia nervosa, an eating disorder in which the patient slowly wastes away to nothing because she has a mental disorder causing her to refuse to eat sufficient food to maintain anything like a normal weight.


Cigna denied payment for all but three of her treatments because its policy contained a 3-visit-per-year limit on behavioral health treatments. There was no such limit in the policy on visits for similar nutritional counseling for ailments outside the boundary of behavioral health, such as heart attacks or diabetes.

Cigna could offer no particular reason for why the policy limited behavioral health visits to 3 per year. In the case from which the settlement evolved, the treating doctor was of the opinion that nutritional counseling would be a key factor in her recovery. In addition, the American Psychiatric Association Guidelines calls nutritional counseling a useful part of the treatment of eating disorders such as anorexia.

Yet, Cigna stood by its 3-visits-a-year limit. As a result of its investigation in this case, New York found that Cigna had enforced its 3-visit limit in about 50 cases, forcing those policyholders to pay more than $30,000 in fees which were to be reimbursed. As part of the settlement, Cigna has agreed to review those claims and pay them.

Why doesn’t the public, including insurance companies, take mental disorders as seriously as physical disorders? For those who are stricken, the anguish, mental torment and heartbreak is very real. The economic cost of trying for a cure is the same or may be even greater than for an illness whicht can be seen on an X-ray.

Why do these types of illnesses generally get second-class status from insurers?
 

Easing The Psychiatric Burden

Anyone who has ever handled a psychiatric disability claim knows they are tough enough to prove. Establishing the existence of a mental condition, which is not easily shown by objective medical evidence (X-ray or MRI), makes experienced and knowledgeable advocacy a must.

Add the burden of showing the disability prevents the claimant from performing employment obligations, as required in any disability income claim, and the matter really gets complicated.

Unless an advocate has had a great deal of experience in proving psychiatric disability claims, insurance carriers are sure to lead them on a merry chase while the client is unable to work or earn money for themselves and their family.

A psychiatric disability claim, is a Perfect Storm favoring the insurance company:

* The claimant is ill.
* The claimant is earning no income to live on.
* The insurance company has the experience, the money and the lawyers to fight on and on and on.
* The claimant has a psychiatric impediment which may affect his or her mental acuity, concentration, or ability to stand up to the pressures of a long-term litigation.

Can you think of a worst case scenario? What better potpourri of negative circumstances could an insurance company ask for in fighting a claim?

Psychiatrists and psychologists treating patients with disability claims should be sensitive to the added problems such claims can cause their patients. No one has to tell these professionals that such basic threats to the patient’s wellbeing have to be dealt with successfully to treat the patient.

The problem is that psychiatrists and psychologists don’t have the training and experience to handle the legal aspects of a successful psychiatric disability claim. They know the client’s medical condition, but have no experience in presenting the claim in the way the insurance company or the law requires, nor can they anticipate the legal impediments which may affect the success or failure of such a claim.

Moreover, the psychologist or psychiatrist faces special ethical constraints when donning the mantle of “advocate” while also trying to heal an ailing patient, given the prohibition against “multiple relationships”. The two roles can easily lead to a conflict, causing failure in both. See, e.g., “Ethical Principles of Psychologists and Code of Conduct”, American Psychological Association, at Sec. 3.05.
 

As part of the treatment in such a case, the treating professional should try to see to it that the patient obtains independent, competent legal help to properly pursue the claim. Neither uncertainty in a patient nor diffusion in a professional’s treatment goal is helpful in a patient’s treatment.

Ideally, the claimant’s disability lawyer should have extensive experience succeeding with psychiatric claims. Through this experience, they will have learned that psychiatric claimants and their treating professionals require the utmost in patience, cooperation and understanding.

On the other hand, insurance companies require just the opposite type of treatment. Attorneys who know the ropes of psychiatric disability insurance claims and aggressively pursue such claims must fight hard, including keeping the insurance company’s hands off patient records they have no right to see.  Hands Off My Info.

The point is that a good, competent, understanding disability lawyer can be an important part of the treatment of a patient with a psychiatric income claim.

Easing claimant anxiety levels is a good thing, especially when the claim involves a psychiatric disability. Having a competent disability advocate with long experience “in the trenches” should help lower a patient’s anxiety level, and makes it easier for the treatment provider to focus on treating the patient’s ailment.