Struggles remain for patients making mental health disability claims

by Leo Almazora28 May 2019

While insurers and employers agree on the legitimacy and seriousness of mental health issues, those who suffer from such conditions still face challenges in getting their claims approved.

“Insurance companies are, for the most part, keenly aware of the need for mental health-related benefits in the workplace and have become significantly better at handling such claims,” reported Global News, citing unnamed sources. “But insurers are also under pressure to keep costs under control and continue to rely on standards and processes that don’t always fit with the realities of mental health illnesses.”

The most obvious problem, according to Toronto employment lawyer Andrew Monkhouse, is the fact that mental illness is less visible than physical ailments. Medical evidence for mental conditions is not as clear-cut as results from a laboratory test; aside from that, there has to be proof that an illness is severe enough to disrupt someone’s job performance.

Lawyers like Monkhouse agree that a general practitioner’s opinion isn’t always enough to sway insurers into accepting a disability claim. They’re more likely to accept one from a specialist — though seeing one can take up to 18 months for Canadians.

HR consultant Julie Holden, who has 15 years of experience in the disability insurance industry, said insurers usually accept reports from family doctors as long as it includes a referral to a specialist. She clarified, however, that GPs must provide medical diagnoses following the Diagnostic and Statistical Manual of Mental Disorders, which provides standard classifications used by North American psychiatrists.

But a specialist’s diagnosis doesn’t always lead to a slam dunk. Mississauga, Ont.-based disability and personal injury lawyer Nainesh Kotak noted that doctors may focus on describing symptoms, but neglect to describe how a disorder prevents a patient from doing their work. Working off of the patient’s job description, he suggested, would be a better approach for medical practitioners.

The insurance industry is working to make things better. The Canadian Life and Health Insurance Association (CLHIA) has worked with the Canadian Medical Assocation in developing a standard physician questionnaire for mental health-related disability claims. And Holden said some carriers, to facilitate treatment and potentially accelerate employees’ recovery, have partnered with third parties to give quicker access to counsellors, psychologists, or psychotherapists.

Lines can blur when the mental illness is claimed to result from an abusive boss or workplace bullying. In such cases, insurance carriers may argue that the problem is a workplace issue. But David Share, president of Share Lawyers in Toronto, noted that a severe-enough disorder could affect someone even in a new job or work environment, and a toxic environment often triggers a pre-existing condition.

Even after getting approved, patients aren’t out of the woods; keeping their benefits for as long as they need entails significant paperwork, including monthly updates from their physician to the insurance carriers. Non-compliance with medication regimens — an issue among some patients with depression or bipolar disorder — could also be considered a breach of contract and grounds for cancellation of benefits.