While most insureds are left in the dark about co-morbidity, insurance companies have always taken the opportunity to abuse claims when it is obvious co-morbidity exists.
The definition, simply put, is “having more than one medical diagnosis that in combination with all other symptoms produces a new disability sufficiently impairing to preclude work.” This is my own definition, by the way, but I believe it’s accurate.
The concept of having more than one thing wrong is omitted by insureds in most disability claims. But, based on my experience as a Consultant, “Disability doesn’t exist in a vacuum.” It’s never just that ligament tear, or the back pain, or the carpal tunnel, but a combination of medical symptoms that removes an individual’s capacity for work.
Unfortunately, nearly all disability insurers take a monumental leap to associate “co-morbidity” to mental health. As a result, thousands of claims are denied under the 24 month mental health provisions.
In 2000, shortly after the Provident takeover, UnumProvident reorganized into “impairment based” file review units. One of them was the Psyche-Cardiac Unit. Although it was quite normal and customary for cardiac patients to seek out therapy for a period of time, Unum took the opportunity to allege that anyone receiving therapy, or counseling, was disabled due to mental health and claims should be denied after 24 months. In other words, while cardiologists were recommending therapy to those who had open heart surgery, Unum was denying those same claims as due to mental health, not cardiac surgery.
In addition, shortly after the merger, Tim Arnold began co-morbid roundtables, but quickly disbanded them when it was discovered too many claims were justifiably paid, not denied. But, there was yet another scam around the corner.
If Unum could medically review each claimed physical impairment separately and eliminate one by one physical diagnosis leaving only mental health issues, then claims could be denied after 24 months. And, the company did this many times over until the California Settlement called them on mental health claim abuses.
The reality is that insureds should always report all of the diagnoses and treatments for impairments that contribute to disability. It is often presumed that more than one diagnosis contributes to the severity of any claimed disability. Withholding medical information that contributes to disability is a very foolish thing to do.
While whole body disability is not evaluated by private insurance, worker’s comp seems to do a better job when considering percentages of whole body disability. This is the difference between “risk management for profit” (private disability) and government/employer subsidies for work injury (workers’ compensation).
Private disability insurers throw out the co-morbid physical impairments and keep mental health because of the 24 month limitation on benefits. As ridiculous as it may sound, it is possible for insureds to have 90% total physical body disability, but no restrictions and limitations that support not working for private insurance. Insurers often depend on the incompetence in reporting by treating physicians.
I know it doesn’t make sense, but all insurers will deny claims after 24 months if they can make a case, regardless how inaccurate, for mental health claims. Of course, mental health isn’t always a co-morbidity. Some insureds have combinations of only physical symptoms such as migraines, intestinal problems, back pain, etc. In these cases, Unum, in particular will play the review-elimination game and wind up with only one that is supported. Guardian has also been known to throw out diagnoses with separate reviews.
It is important for insureds to understand the logic of co-morbidity. Your disability is no longer A, it is not B, but a whole new impairment called C. A+B=C As such, all diagnoses, symptoms, and treatments should always be reported to your disability insurer. Insurers may challenge the co-morbidities, but multiple diagnoses are defensible through patient notes and other lab testing.
