Although most Plans and policies do cover depression and anxiety and mental illness, over time, insurers have developed strategies perceived as prejudicial and biased in order to deny claims after only 24 months of benefits.
To ensure deniability, insurers further added provisions preventing payment of benefits for “subjective” mental illness. The message has always been clear: insurers do not want to pay for mental illness claims, largely because (in the industry’s opinion) they are too easy to fake.
The classic tool used by the insurance industry always has been the Diagnostic Statistical Manual, of which the most current is the DSM-5-TR. The original DSM-5 took effect in 2013 and was controversial from the very beginning.
The DSM-5 created a special category listing “somatoform” illness, meaning “imagined, or exaggerated diagnoses,” and added definitions for “syndromes”. When the word “Syndrome” is attached to a diagnosis it means the disease is not specifically identifiable from any known objective means.The DSM-5 lists diagnoses of depression, anxiety and many others associated with physical disease, which makes it look as though all sickness has some element of mental disorder associated with it.
As you can imagine, insurance companies jumped on the DSM-5 immediately and began citing its classifications as cause to limit benefits to 24-months. The DSM-5 has also been criticized for naming certain disorders that really need not be treated, and classifying Fibromyalgia and Chronic Fatigue as “somataform” illnesses. It is anticipated that a new version of the DSM-5-TR will be completed by 2028.
While it is normal for most manifestations of illness to be accompanied by secondary depression and anxiety, insurers’ strategies document mental illness so that the physical disorder is discredited. In other words, insurers will review, let’s say, a chronic back claim with secondary depression, rule out disability from the back disorder and allege the primary cause of disability is depression, limited to 24 months of benefits.
Unum abused the M&N provision as step further by paying claims for 4 years or so, and then backtracking to allege the claim was always due to depression, then exercising the M&N provision by denying the claim. To my knowledge Unum didn’t make anyone repay any benefits, but it immediately denied the claim.
The State of CA and Multi-State Regulators had a real problem with this and Unum was prohibited from backtracking the M&N Provision.
Another problem with M&N claims is that there always seems to be an aggressive rush by insurers to obtain copies of actual psychotherapy notes. Prudential is infamous for denying M&N claims because the insured, or therapist, refused to release patient notes. Although treatment providers have a great deal of lead way now in NOT providing treatment notes, insurance companies make a big deal out of it. Truth is, under HIPAA, patients have the right to designate their records as Private Health Information (“PHI”) and not release them.
When you think about it, mental health providers write notes for their own benefit, not to support disability. In the view of this Consultant, therapy notes should not be provided to insurance companies who are requesting them so that they can be used to support a claim denial.
But, there is another reason. Providing therapy. notes to insurance companies undermines the purpose of the therapy itself. How honest and confiding would the patient really be if they knew the information would be read by an insurance company? Would you share your innermost secrets? I know, I wouldn’t. And if, confidential information isn’t totally shared with a therapist, how beneficial could the therapy be?
Insurance companies seek out patient therapy notes to see if there is any real information they can use alleging work capacity. Therapy notes are always more socially oriented, and there are comments as to how “much better” the patient seems to be getting along. Just the “catch” insurance companies are looking for.
While insurance companies are using the DSM-5 to classify somataform diseases as “just in your head”, patients are not receiving the benefits they are entitled to. It’s the old story of insurers aggressively searching for reasons to deny claims. Why do you think insurers harass you for copies of your SSDI file? Form 831 documents the listing under which your SSDI benefits were approved. They are looking for mental health listings so they can say, “See, we agree with SSDI that your disability is due to mental health reasons.” Form 831 also gives the name of the DDS (Disability Determination Specialist), which at one time Unum jumped on and started contacting that person with the insured on the line.
Bottom line here, disability insurers do not want to pay LTD claims to age 65 0r 67; they want the claims shut down after 24 months. My recommendation is to make sure that secondary depression and anxiety be ICD-10 coded F06.30 “Mode disorder due to known physiological disorder. And be aware of the tactics that are being used against your claim.
