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.

The Chicken Or...

The chicken or the egg question is a tough one to answer, but not for disability insurance carriers. Whichever answer permits them to stop disability income payments to a claimant is the right one for them.

Recently, a Federal District Court in Pennsylvania ruled against Prudential even after giving the company the benefit of the deference rule in making its decision. Ironically, the claimant was a former Prudential life insurance salesman. See Morgan v. Prudential Ins. Co., 2010 WL 5097811 (E.D., Pa.).

The issue is a common one. The claimant suffered from fibromyalgia, but also was afflicted with anxiety and depression, mental conditions which under the terms of the policy would limit his disability benefits to 2 years.

As a matter of course, Prudential jumped on the fact that its former employee suffered from anxiety and depression and limited disability benefits to only two years. (If Pru had done anything else, it probably would have been cashiered from the disability income insurance company “union”).

Although the insurer was quick to jump on the psychiatric ailment as a foundation for halting disability payments, the court said: “Not so fast". The court analyzed the situation as one in which the fibromyalgia was the cause of the disability while the psychiatric problems resulted from the disability caused by the fibromyalgia.

The Federal District Court set forth in easy to understand terms the rationale for deciding which impairment is the cause of a disability:

“…A mental illness secondary to a physical condition is not the cause of the physical condition and the resulting disability. If but for the physical condition there would be no mental illness, the latter cannot be considered a cause of an impairment. Even if the mental illness contributes to the impairment causing the disability, it is the physical condition, not the mental condition, that is the cause of the disability. Otherwise, whenever a claimant’s physical disease or condition causes anxiety and depression, the mental illness limitation would always apply…”

In the world of disability income insurance, insurers seem almost automatically to find that any psychiatric problems came first and therefore disability benefits, if any, are limited pursuant to the policy language.

However, as the Morgan Court so wisely pointed out, a physical disability which afflicts a healthy person and prevents that person from earning a living, thereby severely upsetting that person’s way of life, ordinarily causes that person to suffer from anxiety and depression. To suffer a mental collapse from such overwhelming circumstances is certainly not surprising.

But, to insurance companies which have to pay disability benefits for which they have already received premiums, it can be a windfall. If they take the position that the mental illness caused the disability, benefits may be limited by the policy terms (usually 2 years for mental illness).

When there is a question of mental stress as there is in many disabilities where a person’s livelihood is cut off, insurers are certain to decide that the mental illness came first.

But, when judges evaluate the evidence, as the Court did in Morgan, even giving Prudential deference, the Court found that the fibromyalgia came first and the mental problems later. When that is the case, the mental illness limitation doesn’t apply.

This ruling doesn’t answer the chicken or the egg question, but it makes perfect sense to us.