Hello. I’m a Licensed Clinical Psychologist practicing in New Brunswick. I have a client who sought mental health services. During our treatment, she has had her claim for LTD denied. I am not the physician who originally diagnosed her or put her on leave from her employment. Her diagnosis has been confirmed by myself and a psychiatrist. I believe she is being discriminated against by her insurance provider due to myths about mental health. She is being expected to travel outside of province for an independent medical evaluation. This requirement, and the initial denial of the claim, have only served to exacerbate her condition. What, if anything can I do? Can a human rights complaint (or some other punitive action) be taken against this insurance company?
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Why does the insurance company want another medical opinion?
What reason did they give?
They denied her claim for LTD. She submitted an appeal, for which I provided a letter of support, indicating that she was seeing me, what for, and what her treatment is. But I understand the opinion is part of the appeal process.
Appeal process for Insurers often is used as a way for them to try and prove they acted fairly in denying the claim. It is often a way to pad the claim file in the Insurers favour.
How you can help as a psychologist is by providing objective proof of her condition ie: Beck depression Inventory and other quick assessments.
In your letter give professional opinion on why going back to employment at this time is ill advised. Does the insured have suicidal thoughts?
Include journal or other peer reviewed articles outlining the insureds condition. Give examples of the insureds job duties and why in your opinion that he or she is unable to do at this time.
You can not give legal advice but you could provide this site as a resource for your client to see what options are available or to ask questions.
If you, the psychiatrist and the family doctor advise against travelling for an IME that would be helpful.
Anytime an Insurer can exploit the stigmatized diagnosis of mental health, chronic pain and such -they will often do so.
The IME realistically is being set up for the Insurer to continue padding the file against the Insured. ie: To support a denial and to try to reduce a bad faith claim later. Insurers only spend money to save money**
Make sure any letter of support does not read as advocacy but is based on objective data and professional opinion.
Please send them to this site.
Is there a reason the letter of support should not read as advocacy? Because what I currently have drafted (but have not yet sent) definitely reads that way – I’m very angry with how they have treated my client.
There is a fine line of advocacy and professional opinion. Your professional opinion can be that your clients condition is regressing due to the reported conduct of the Insurer. You should write it as if it were to be one day read by a judge.
ie: a brief summary of the circumstances of the injury or condition
the nature of the injury/condition
the extent of the injury/condition
the treatment prescribed;
the severity and location of pain or impairment
a prognosis as to the duration of the injury or condition-ok to put unknown at this time
the degree of the present and residual impairment.
You can advocate as long as you have support for your professional opinion. A clear statement of any specific questions that your client is requesting to be included. Just review it as it would one day be read by a judge or colleague–You want the support not to be challenged as bias is all.
You are a great psychologist and mental health specialist to care so much. You rock. I am not a lawyer–so go with your instinct.
Attach symptoms and criteria for the condition/diagnosis would be helpful ie:
12.04 Affective disorders: Characterized by a disturbance of mood, accompanied by a full or
partial manic or depressive syndrome. Mood refers to a prolonged emotion that colors the whole
psychic life; it generally involves either depression or elation.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied, or when the requirements in C are satisfied.
A. Medically documented persistence, either continuous or intermittent, of one of the following:
- Depressive syndrome characterized by at least four of the following:
a. Anhedonia or pervasive loss of interest in almost all activities; or
b. Appetite disturbance with change in weight; or
c. Sleep disturbance; or
d. Psychomotor agitation or retardation; or
e. Decreased energy; or
f. Feelings of guilt or worthlessness; or
g. Difficulty concentrating or thinking; or
h. Thoughts of suicide; or
i. Hallucinations, delusions, or paranoid thinking; or
- Manic syndrome characterized by at least three of the following:
a. Hyperactivity; or
b. Pressure of speech; or
c. Flight of ideas; or
d. Inflated self-esteem; or
e. Decreased need for sleep; or
f. Easy distractibility; or
g. Involvement in activities that have a high probability of painful consequences which are not
h. Hallucinations, delusions or paranoid thinking; or
- Bipolar syndrome with a history of episodic periods manifested by the full symptomatic picture
of both manic and depressive syndromes (and currently characterized by either or both
B. Resulting in at least two of the following:
- Marked restriction of activities of daily living; or
- Marked difficulties in maintaining social functioning; or
- Marked difficulties in maintaining concentration, persistence, or pace; or
- Repeated episodes of decompensation, each of extended duration;
C. Medically documented history of a chronic affective disorder of at least 2 years’ duration that
has caused more than a minimal limitation of ability to do basic work activities, with symptoms or
signs currently attenuated by medication or psychosocial support, and one of the following:
- Repeated episodes of decompensation, each of extended duration; or
- A residual disease process that has resulted in such marginal adjustment that even a minimal
increase in mental demands or change in the environment would be predicted to cause the
individual to decompensate; or 3. Current history of 1 or more years’ inability to function
outside a highly supportive living arrangement, with an indication of continued need for such
Listing of Impairment specified in the preceding letter
Source: June 2006 SSA Blue Book
Thank you. I appreciate you saying that. I just hope I can help.
Sorry, I am just seeing this thread now. You want to avoid having a tone of advocacy in your report if possible. You want to be as objective as possible and avoid venting your frustration at the insurance company.
Unfortunately, it is often necessary to take legal action on long-term disability claims involving depression, anxiety, etc. There are certainly strategies to maximize the chances of having claim approved by insurer, but more often than not it will take legal action. Often they will approve the claim fairly quickly once legal action has started.
Please feel free to reach out to me personally if you want to discuss further.
Disability Lawyer with Resolute Legal
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