Diagnoses of mental and nervous disorders are rising along with the work leaves associated with them. And as the World Health Organization has noted, depression is the leading cause of ill health and disability worldwide.
According to the recently released disability claims management benchmarks survey from RGA Life Reinsurance Co. of Canada, Canadian carriers saw an overall increase of seven per cent in long-term disability claims related to mental illness over the past two years. There are different rationales that could explain the significant increase. For example, some people will say that there was a rise in work-related stress, while others will point to a reduction of the stigma associated with mental illnesses that could influence people to seek care. This increase in claims leaves case managers to face important challenges when it comes to the initial decision or the adjudication of the files.
Case managers play an important role and can actively work with the claimant and the employer to support a positive resolution of the claim. Not so long ago, case managers learned that, when analyzing the initial forms, if they had “a diagnosis, the presence of symptoms and a treatment,” they could then approve a disability claim. In the last few years, the industry has started to move to an era where the focus is now on the employee’s functional limitations and capacities.
Upon receipt of a claim, even before conducting the telephone interviews, the case manager’s first action should be to compare all of the information: the initial forms, the medical information and the contractual provisions.
In every case, case managers should complete a comprehensive telephone interview with the claimant and the employer to compare their versions with the medical information. They should always keep in mind that the main task is to assess the employee’s functional limitations and capacities and compare them with the work demands. Obtaining information about the employee’s capabilities with regard to activities of daily living is also important because, if the alleged symptoms and functional limitations are inconsistent with them, the case manager should dig deeper.
If there are inconsistencies, the case manager should document the file as needed by, for example, getting a copy of the medical records, including test results and specialist reports. Obtaining all available medical information is necessary in order to discover and assess what the employee discussed during visits with the doctor.
When all of the information needed to assess the claim is in hand, the case manager now has to make a decision. It’s often a good idea to have a claim discussion with internal resources to ensure the case manager makes the right decision.
If the case manager approves the claim, the real challenge starts. If the case manager determined there are functional limitations that are incompatible with the job demands, his or her goal will now be to help the employee through the return-to-work process. Critical thinking, creativity and innovation are the keys to effective assistance, as each situation is unique and deserves its own solutions.
The attitude the case manager brings to the process also plays a critical role in the resolution of the claim. The ultimate goal is to support the reintegration of the employee back into the workplace. The case manager should always communicate with a clear intent and not send mixed messages. For example, sending Canadian Pension Plan forms or social security disability insurance forms to the claimant when the case manager is trying to support a return to work can be confusing. The case manager needs strong communication skills and should conduct timely followups with both the employee and the employer during the leave of absence and the reintegration period (whether that involves a progressive return to work or accommodations). Facilitating the communication with all parties involved is a must.
The longer a disability lasts, the greater the chances are that the illness becomes chronic and the lower the likelihood that the employee returns to work. The case manager’s initial decision and the ongoing management of the approved claim are keys to success.
Here are some takeaways for case managers handling these kinds of claims:
- Do complete telephone interviews with the claimant and the employer;
- Compare all of the versions (including medical, employee and employer notes);
- Obtain all of the information available;
- Be alert to red flags and inconsistencies;
- Remember that a work-related issue often leads to negative symptoms that aren’t necessarily disabling;
- Assess the employee’s functional limitations and capacities and compare the differences and the similarities between them for both the work and home environments;
- If the case manager approves the claim, the use of tools can be helpful;
- Be creative and always manage the claim with a positive but firm approach; and
- The attitude and the communication skills of the case manager are key to successful outcomes.
Marie-Julie Allaire is a senior group claims consultant at RGA Canada.