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comorbidityTwo of the most commonly misused insurance terms are “Mortality Values” and “Comorbidity.” Actuarial “mortality values” are used in the Life insurance underwriting process where hazards and perils are charted with sex, age, gender etc. to determine premium for Life insurance policies.

“Comorbidity”, on the other hand, is used in the disability claim review process to determine the overall effects of multiple diagnoses on functional capacity and the inability to work. Well…..it SHOULD be considered, but the truth is, it isn’t.

Most insureds mistakenly believe that they should be considered severely impaired when they have been diagnosed with more than one medical condition. In one sense this is true, but I would describe comorbidity as “differently defined disability” based on the combination of diagnoses rather than from just one impairment.

Logically, the comorbidity and disability relationship can be defined as A+B=C. Insureds who are diagnosed with multiple impairments no longer have just “A”, or just “B”, but “C” representing a whole new primary diagnosis definition giving weight to the combined medical symptomology that is causing someone not to be able to work.

While insurers have traditionally “played around with consideration of comorbidity” in the review process, ultimately paying claims based on “C”, the newly defined impairment, becomes too costly and consideration is abandoned. Such was the case of Unum’s MDR (Multi-Discipline Roundtables) where nearly every claim presented was determined to be payable – far too costly to keep in the review process.

Therefore, nearly every insurer in the U.S. uses what I call the “throw away diagnosis review” to eliminate one diagnosis at a time until there are no primary diagnosis’s on which to pay the claim.

For example, let’s say a Hartford insured was diagnosed with coronary artery disease, colitis, chronic pain due to failed back surgeries, and depression. To begin, Hartford’s claim rep will send the claim to a cardiologist to determine if there are medical restrictions and limitations that preclude working due to heart disease.This reviewer says, “No”, the patient can work.

Next, the claim is reviewed by a gastroenterologist who again looks at the evidence just for colitis and reports, “No”, the patient can work. Following, records are sent to a PM&R doctor who reviews for pain and residual effects from surgeries. Once more, the answer is “No” this patient can work. Next, a psychiatrist reviews and says “Yes” this patient is impaired.

Great…the insurance company now concludes that the primary cause of the disability is depression and limits benefits to 24 months if the Plan or policy allows it. In this example, The Hartford systematically eliminated each physical diagnosis from liability acceptance leaving only depression, coincidentally the only M&N diagnosis limited to 24 months of paid benefits.

In reality the formula review for this example should have been A+B+C+D=E, where all of the combined symptoms and functional capacity are reviewed consecutively to determine multiple effects of ALL diagnoses on the inability to work.

Clearly, severe pain negatively affects CAD, and irritates colitis resulting in more severe symptoms, which causes depression. It isn’t that difficult to see, but yet insurers would have to pay too many claims if the comorbidity was considered resulting in “E”;  and, therein lies the missing link when multiple impairments are evaluated separately rather than determining the “totality of disability” from multiple symptoms – “E” in the equation.

Insureds continue to be victims of “comorbidity omission” within the claims review process. Even IME physicians buy into the “impairment isolated” review process, even when they are unqualified to comment on several of the impairment specialties.

Any prudent, reasonable review of comorbidity in the medical disability review process will eventually conclude that multiple diagnoses, when symptoms are reviewed collectively, create an entirely new disability (“E”) with lack of functional capacity reflective of all of the diagnoses, not just one.

In 2004, Unum’s Multi-State Settlement Agreement found Unum’s unfair claims practices included omission of consideration of comorbidity, and required the company to consider the combined effects of multiple impairments, Sadly, like everything else the Multi-State Settlement required, Unum continues to ignore comorbidity and eliminates impairments one-by- one from benefit payments.

An added note here……Some insureds do not report comorbidity (multiple diagnoses) to insurers mistakenly thinking that only one diagnosis should be reported. Or, that the cause of disability originally submitted can be the only one reported. That belief is wrong.

Comorbidity, or multiple diagnoses should ALWAYS be reported listing diagnoses as either “Primary” or “Secondary”. If more than one diagnosis is contributing to your overall lack of functional capacity, it should always be reported.

consultingIf you are having difficulty with any issue concerning your claim, please feel free to give me a call about coming on board as a client.

DCS is a national consulting organization that provides expert claims management services to those with private insurance. I offer free initial consultation and I’m happy to discuss how you can become a DCS client.

If you need assistance with filling out your update forms or questionnaires, please feel free to give me a call. The role of a Consultant is to assist you with managing your claim through administrative assistance, expert claims advice, completion of forms, and providing resources to help you make good decisions concerning your claim.

If you are interested in becoming a DCS client, I invite you to visit my website at: http://www.disabilityclaimssolutions.com