DCS Inc. – Specialty Impairment Claims Management

Insurance claimsAlthough in recent years I’ve ignored writing about various impairments I’ve gained an expertise with, I think it is a good idea on the cusp of a new year to mention the dedicated areas of expertise that has taken me 25 years to gain and pass on in the form of successfully paid claims.

HIV claims management has always been at the top of my list as an impairment that requires detailed claims management skills. As modern advances have progressed in the last 20 years, insurers are more inclined to allege that a diagnosis of HIV does not necessarily signal total disability.

While insurers such as Unum, MetLife and The Hartford have traditionally targeted those diagnosed with HIV/AIDS due to advances in medications, most HIV patients are still unable to return to work due to residual side-effects and/or continued symptoms. Insurers don’t want to hear it!

Although improved medication trials keep lab report numbers normal, it is likely that HIV patients continue to suffer from symptoms such as chronic diarrhea, peripheral neuropathy, dizziness, and susceptibility to bacterial infection. Therefore, HIV patients with normal T-cell counts, but suffering continued symptoms, may file for total disability, but the application requires specialized medical management. HIV is no longer considered a disabling impairment even when patients continue to suffer symptoms severe enough to preclude work.

While in the past rheumatologists prescribed morphine pumps for Fibromyalgia patients it is no longer true today. Fibromyalgia and Chronic Fatigue have transitioned via the new DSM-5 into somatoform mental illness. Although most rheumatologists continue to treat FMS and CFS, the percentages of treating physicians who actually accept that FMS is permanently disabling is estimated to be less than 50%.

Therefore, patients diagnosed with FMS and CFS are often labeled by insurers as having “self-reported” and/or mental illness rather than physical disease. Benefits are limited to 24 months. A few insurers have closed the loopholes in both ERISA Plans and IDI policies by specifically excluding “connective tissue disease” or Fibromyalgia specifically in policy provisions. Or, various Plans often cite Fibromyalgia as an impairment that is only paid for 24 months.

Although most physicians continue to cite FMS as a “physical” syndrome, most insurers now follow the DSM-5 in identifying the impairment as “all in your head.” Again, FMS and CFS claims generally require some degree of claims expertise to manage.

(By the way, any disease that is classified as a “syndrome” is assumed to be subjective because there is no objective evidence to prove what patients and doctors claim they have. Examples are of course, Fibromyalgia Syndrome, Chronic Fatigue Syndrome, Postural Orthostatic Syndrome (POTS), Chronic Pain Syndrome, and Complex Regional Pain Syndrome (CRPS) etc. These are most notably the impairments disability insurers target and often refuse to pay, and are the areas of my expertise.)

Chronic pain also requires a “positioning” with most disability insurers in that the impairment is most often immediately classified as “subjective”. Most insurers will immediately classify “chronic pain” as mental and nervous, limited to 24 months, if the primary diagnosis is just listed as “chronic pain.”

For the most part chronic pain is the result of other diagnoses such as lumbar radiculopathy, disc herniation, cervical issues and so on. Physician documentation of the primary disability as “chronic pain” often brings on insurer hellfire listing the cause of disability as “subjective” and subject to 24 months. The real primary diagnosis, such as disc herniation with nerve involvement is left out of the documentation and insureds suddenly find themselves facing termination of benefits in 24 months.

Chronic pain, in my opinion should most often be listed as a “symptom”, not a primary diagnosis. Interestingly, there is objective evidence for sources of pain while ” chronic pain” listed as a primary diagnosis is subjective. Still, not knowing the significance of a symptom vs. diagnosis, most insureds will allow this situation to get out of hand for quite some time before trying to do something about it. Again, this type of claim requires some specialized knowledge to manage successfully.

Admittedly, there are some claim situations that require expert claims management – not legal expertise mind you, but real claims management know-how. As we transition into 2019 tomorrow, please keep in mind that there are some claims with unique circumstances that require real hands on claims experience and expertise management.

I wish all of you a very Happy New Year. Please stay safe in your celebrations, and I’ll be here on the other side.