Psychiatrists Evaluating More Disability Claims

To reduce potential fraud, insurers are increasingly asking psychiatrists to conduct independent evaluations of disability claims submitted by physicians.

Insurers have been losing money because of a 63 percent increase in the number of professionals including physicians filing disability claims between 1989 and 1994, according to Barry Wall, M.D., a forensic psychiatrist who spoke at APA's 1998 annual meeting in Toronto in June.

The insurance industry says physicians are the greatest offenders, especially orthopedic surgeons, neurosurgeons, thoracic surgeons, anesthesiologists, and emergency room physicians, noted Wall, a clinical assistant professor of psychiatry and human behavior at Brown University School of Medicine in Providence, R.I.

Psychiatric disorders, in particular depression, were responsible for 18 percent of the total claims paid during that period by Paul Revere Insurance Company in Worcester, Mass., the largest supplier of individual disability insurance in the nation, said Wall.

In contrast, musculoskeletal ailments, the most common injury among physicians, made up 35 percent of total claims paid by the same insurance company.

Disability insurance companies attribute the increase in physician claims to several factors, according to Wall.

• The subjective nature of psychiatric claims: Physicians may feign some psychiatric symptoms; psychiatric illnesses often lack standardized treatment plans for the same disorder; and psychiatrists treating patients with claims often inform the insurance company that revoking reimbursement will cause a relapse of the patient's condition.



• Liberal policies issued between 1985 and 1989: Some policies, for example, narrowed the scope of disability to not being able to perform one's own occupation, which made it easier to collect benefits.



• Higher income: Claimants with more than one disability insurance policy can collect income that is higher than they are able to earn on the job.



• Managed care: Physicians are more commonly experiencing diminished job satisfaction and earning lower salaries resulting from high managed care penetration. Physicians in southern California and southern Florida, where penetration is particularly high, have filed five times more disability claims than physicians in other parts of the country.



• Other economic factors: The economic pressures of running a practice have pushed some physicians with medical problems to file psychiatric disability claims.

To control the costs of rising claims, the insurance industry has changed the terms of existing disability policies for physicians. For example, Paul Revere has put caps on specific dollar amounts to be collected monthly.

New policies have less generous terms including limiting or eliminating disability coverage that applies to only one's own occupation and cost-of-living adjustments. Psychiatric disability benefits have been limited to a two-year period by several companies, although this provision is being tested in various courts. Moreover, some companies no longer approve coverage for customers who have been in psychotherapy within five years of submitting an application.

Insurers are also asking psychiatrists to conduct independent evaluations of more psychiatric disability claims by physicians, observed Wall.

Kenneth Appelbaum, M.D., another panelist, commented that "claimants tend to approach these examinations cautiously, some even making veiled or explicit threats against the examiner." Appelbaum is an associate professor of clinical psychiatry and codirector of the Law and Psychiatry Program at the University of Massachusetts Medical Center in Worcester.

"Insurance companies also approach these examinations cautiously because if they deny benefits and the decision is later overturned by the courts, punitive damages can be triple the initial payout."

Appelbaum recommended that psychiatrists follow certain guidelines when conducting an independent medical evaluation.

• Tell the examinee the purpose of the examination. State that the information obtained will be conveyed to the insurer and that no doctor-patient relationship exists.



• In addition to making a comprehensive psychiatric assessment, it's important to include the following information: the claimant's current income, disability benefits and policy terms, current symptoms and stressors, a description of the claimant's typical day before and after the onset of disability, and future plans and self-prognosis.



• If malingering is suspected, focus on discrepancies in the information rather than becoming argumentative.



• To supplement note taking, record the interview on audiotape or videotape with the insurer's and claimant's consent. "This verbatim record can be useful if the evaluation is challenged by the claimant or the case is further appealed or goes to trial," said Appelbaum.

He also recommended obtaining information from multiple sources and psychological testing to corroborate the claimant's report and increase the degree of certainty and credibility of the evaluator's opinions.

Surveillance of the claimant should also be considered to assess the claimant's credibility especially when having difficulty obtaining outside sources of information.