People cannot choose a disease that disables them so much that they are unable to work, but insurance companies have the power to approve or deny claims based on where in the body the condition is located. Masu.
It’s this disconnect that Jessa Victor, a shareholder attorney in Hawkes Quindell’s Madison office, specializes in. She has seen people with mental illnesses denied long-term disability compensation, potentially putting them in situations they would never face if they had a problem. It was physical.
“Every time someone calls me for help with a disability, they say this — and everyone says this — ‘I never thought I’d be in this position. ‘I never thought I’d need insurance,’ Victor said.
Mental health insurance seems to be stuck in a time warp. Here are some important questions and answers.
How are physical and mental health-related disabilities treated by insurance companies?
People who have a physical illness that impairs their ability to work can apply for long-term disability insurance after being out of work for 90 to 180 days. This process typically occurs after short-term disability insurance.
If approved, the person can receive a portion of their income until retirement age.
However, when people suffering from behavioral health conditions apply for long-term disability compensation, they are denied at a much higher rate, and even if approved, they only receive compensation for 24 months.
Details: Are you physically disabled? No problem. Mentally disabled? Coverage is limited and difficult to obtain.
Details: You have a mental disorder. Insurance and vacation are required. Please brace yourself.
And as long as you stay with the same employer, your vacation accrues. For example, someone who took three months off this year will only have 21 months left as long as they remain with their employer.
Additionally, if someone with a physical illness has secondary mental health conditions (such as depression due to chronic back pain), that can also trigger a 24-month restriction.
How many employees claim disability related to mental health and substance use disorders?
Nationally, 7% to 8% of long-term disability claims are related to mental health, according to Richard Leavitt, consulting actuary and disability reinsurance risk manager and consultant at Smith Group. Estimated.
How often are mental health-related disability claims rejected?
Companies are under no obligation to disclose such data. But reports from the few companies that publish data, including third-party claims management company Sedgwick, show that mental health claims are almost twice as likely to be denied as other claims. It has been shown that
Why are so many mental health claims denied?
The national psychiatrist shortage certainly affects someone’s chances. More than 150 million people live in federally designated mental health professional shortage areas, making it difficult to receive proper evaluations.
But for those who have a mental health professional, a different problem arises. An insurance company can hire a mental health expert to review someone’s medical documents, and that evaluation can override a claimant’s expert team. Mark Debofsky, a principal attorney at the Debofsky Law Firm in Chicago and a member of the 2023 ERISA Advisory Committee, says that even if a medical professional is hired by an insurance company and makes an inaccurate determination, there is no remedy. He said there are few options.
“They’re not facing potential malpractice liability. In this case, they’re just giving an opinion,” Debofsky said. “And there is no responsibility for holding such an opinion.”
What is a discretionary clause?
Victor said insurance companies almost always have an advantage because of “discretion clauses” for people who are suing to have claims denied because of mental health or addiction. Essentially, insurance companies can interpret the terms of their plans and decide whether they see fit or not.
Victor said the judge’s role in these cases is not to decide whether someone has a disabling condition and should have been paid benefits. Rather, the question is whether the way the insurance company interpreted its insurance contract was reasonable.
“The insurance company’s decision is given the benefit of the doubt, even if the judge disagrees with the decision,” Victor said. “Unless it can be shown that the decision is unreasonable, the decision must be upheld.”
Discretion clauses are prohibited in 20 states. But Wisconsin is not among them.
Have you been denied disability compensation due to a mental health or substance use disorder?
The Journal Sentinel continues to research and flesh out its series, “The Nervous Limitation,” and wants to hear from people in Wisconsin who have been affected by insurance companies denying disability coverage. Note that this is separate from Social Security Disability Insurance and Supplemental Security Income.
Fill out the form below or contact Natalie Eilbert at neilbert@gannett.com.
Natalie Eilbert reports on the intersection of disability insurance and mental health through a grant from the USC Annenberg Center for Health Journalism’s 2024 National Fellowship Fund. The Center has no role in editing or publishing her work.
Eilbert covers mental health issues for the Milwaukee Journal Sentinel. She welcomes story tips and feedback. Contact her at neilbert@gannett.com or visit her X (Twitter) profile at: @natalie_eilbert.