A 2023 survey conducted by the Canadian Federation of Independent Business reported Canadian physicians spent 48.8 million hours annually on administrative tasks or the equivalent of 55.6 million patient visits,1 a proportion of which was dedicated to completing electronic health records and insurance forms for disability claims. Physicians have expressed frustration about the volume of requests from insurers required to support patients’ disability claims. Similarly, insurers lament information provided by physicians often lacks sufficient detail for the purposes of adjudication. Achieving a shared understanding is crucial to reducing the frustration experienced by both groups and the negative impact on claimants. It is important to acknowledge both clinicians and insurers are invested in restoring individuals with disabilities to a state of well-being, with each playing a unique role. Practitioners provide initial diagnosis, associated symptoms, proposed treatment plan, and prognosis. Insurers consider information as it relates to a claimant’s essential work functions to determine whether the condition meets the definition of total disability as defined in the insured’s policy. This article elaborates on information needed by insurers and how it is used in disability claims.
Diagnosis and symptoms
The diagnosis field of an insurer’s attending physician’s statement (APS) asks practitioners to provide the working diagnosis. Diagnoses should conform to nomenclature used in the most recent editions of either the Diagnostic and Statistical Manual of Mental Disorders2 or the International Classification of Diseases.3 Difficulty arises when practitioners use common terms like depression rather than the more formal major depressive disorder. King notes that “when categories are too broad and diffuse, they are not particularly useful.”4 A precise diagnosis guides selection of evidence-based treatment aimed at restoring well-being.
The APS includes a field for listing patients’ symptoms. Both the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases specify thresholds for the number of symptoms required to confer a specific diagnosis, with the added requirement that symptoms cause substantial distress or impairment in social and occupational functioning.2,3 Practitioners should provide a complete list of symptoms identified during examination, ensuring the number and severity of symptoms are consistent with the assigned diagnosis. This is especially important in the case of mental disorders, as considerable symptom overlap exists across diagnoses. However, neither symptoms nor diagnoses are sufficient to establish the presence of disability. Disability is determined by considering functional impairments and the context in which they occur. Although impairments and symptoms are correlated, they are distinct and need to be assessed separately. Disability determination hinges on consideration of 3 factors: relevance of impairments to the individual’s essential work functions; severity; and frequency of occurrence.5 Including such details on disability forms is invaluable to clinicians working to facilitate patient recovery and essential to ensuring a just and fair decision by insurers adjudicating claims.
Treatment and prognosis
There is considerable variability among practitioners when completing the treatment field of the APS, both with respect to comprehensiveness and emphasis. It is in this realm that expectations and working assumptions of insurers and practitioners can clash and become a source of mistrust that contributes to eroding collaboration that is vital to addressing the needs of patients. Ideally, treatment should begin before the onset of a disability leave. Supporting individuals to remain at work by initiating early treatment curtails progression of prolonged disability and suffering.6
Treatments of disability due to mental disorder typically include a combination of pharmacotherapy, psychotherapy, and behavioural activation—a triad that requires engaging medical practitioners, qualified mental health professionals, and ongoing interprofessional communication and collaboration. Protocols that provide clear plans and timelines for expected progress have shown promise in reducing disability duration and building trust between insurers and practitioners. Promising recovery rates were achieved when treatments focused on factors such as chronic job strain, low job control, limited social support, perceived injustice or unfairness in the workplace, and high job insecurity.7,8 Further, use of symptom measures with established reliability and validity such as the Generalized Anxiety Disorder 7-item scale, the Patient Health Questionnaire–9, or the Sheehan Disability Scale can aid diagnosis, facilitate monitoring of treatment response, and establish optimal timing for return-to-work planning. Patients with limited coverage for mental health treatment are often encouraged to access employee assistance programs that provide short-term interventions. However, we would note treatments that are not well aligned to patient needs and condition severity can cause iatrogenic symptoms.
Conclusion
Restoring a patient to a state of well-being requires a shared understanding and collaboration among insurers, practitioners, employers, and the affected individual. This overview of the requisite information for just and accurate disability determination and effective clinical management of mental disorders helps advance this objective. It is a first step that can be built upon by encouraging the dedication of more continuing medical education credits to the effective management of disability due to mental disorder in primary care. It is our position that a shared understanding of disability will serve the betterment of those affected by mental disorders.
Notes
We encourage readers to share some of their practice experience: the neat little tricks that solve difficult clinical situations. Praxis articles can be submitted online at http://mc.manuscriptcentral.com/cfp or through the CFP website (https://www.cfp.ca) under “Authors and Reviewers.”
Footnotes
Competing interests
None declared
This article has been peer reviewed.
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