Has your mental illness disability claim been denied? Are you worried your long-term disability payments are about to be cut off?
In this article, I review the top five reasons why mental illness disability claims are denied. I also explain what you can do to avoid a denial or at least minimize your chances of denial.
As a disability claim lawyer, a large percentage of the cases I handle involve mental illness claims for disability benefits. In fact, mental illness is one of the leading causes of disability in Canada.
I constantly see the same reasons why depression, anxiety and other mental illness disability claims are denied, or payments are cut off by insurance companies. My goal with this article is to educate you about the most common (and avoidable) reasons for denial so you can avoid making these mistakes and give yourself the best chance at getting approved.
This article is part of a guide on medical conditions that qualify for disability benefits. For more inquiries about disability benefits and the conditions that qualify, take a look at the articles below:
Why Mental Illness Disability Claims are Denied: The Big Picture
Before I get into the reasons why mental illness disability claims are denied, it is important to step back and look at the bigger picture. This will give you the context to understand the unique challenges of mental illness disability claims.
Mental illness represents the most common reason for disability in the workplace. Over the past decade, insurance companies have seen a rise in the number of disability claims for mental illness. The insurance industry has taken measures to manage mental health-related disability claims.
This “management” ranges from excluding mental illness claims completely in some insurance policies to creating specific internal policies and procedures for handling disability claims.
As a general rule, mental illness disability claims will get special treatment by the insurance company. A common tactic is for the insurer to argue your mental illness was caused by a “toxic work environment.” This allows them to deny you benefits because you would not be covered under the insurance policy.
In my experience, it is harder to get a mental illness claim approved (as compared to other medical conditions). And even when they get approved, mental illness claims are more likely to be terminated within two years. This is because of the insurer’s desire to control claims costs in the face of increasing numbers of mental illness claims.
This all leads back to the fact that mental illness is a treatable condition. However, a positive treatment outcome requires best practices for medical care. It also requires that you be an active participant in the treatment. If the insurance company doesn’t see evidence of best practices of medical care and active engagement by you, then your claim will get denied.
Related reading: Mental Illness Disability Benefits in Canada
Medical Records in Mental Illness Disability Claims
In my experience, you have to carefully handle your mental illness disability claim in order to win or prevent losing disability payments.
I have worked with many people who have been denied disability benefits for mental illness, even though they are truly disabled. In these situations, the insurance company often has legitimate reasons to deny the disability claim — even though the person is honest and legitimately disabled.
Being honest and legitimately disabled is not enough to win disability benefits. With disability claims for mental illness, insurance companies will judge your case based on the medical records in its possession. If the medical records don’t accurately document the reality of your situation, then the insurance company bases its decision on the impression created by the records, not the actual reality of your situation.
Therefore, with a mental illness disability claim, your primary goal must be to make sure your medical records accurately communicate the reality of your situation.
With all this in mind, let’s turn to the top 5 reasons why mental illness disability claims are denied.
Top 5 Reasons Why Mental Illness Claims are Denied (and what you can do about it)
When reading these reasons, keep in mind that they actually build on one another. So, you need to address all of the reasons listed to avoid a denial. Finally, these reasons address what I call “legitimate reasons for denial” rather than a bad faith denial by a rogue claims handler. Unfortunately, there are times when an insurance company will deny a legitimate disability claim, even when it is well-documented. That is when you need to call a lawyer because they are not acting fairly.
Reason 1: You are not getting regular care from a family doctor
All insurance policies and disability programs require you to get “regular care” from a physician. This means you need to visit a doctor on a regular basis. What is a “regular basis”? That will depend on your type of mental illness and the treatment you are getting.
The key point is that you have to show you want to get better and that you and your doctor are working towards that. Or at the very least, that you have explored all options for improving your medical condition.
Getting “regular care” from your doctor usually means you are seeing your doctor on a bi-weekly or monthly basis. In treating mental illness, the best medical practice is often to prescribe medication to you. Normally, medication prescribed to treat mental illness needs to be carefully monitored and tweaked depending on how you respond to the treatment. If a medication proves ineffective, you may need to go off it and start another. The point is that your treatment needs to be carefully monitored on an ongoing basis.
If you are not seeing your doctor on a regular basis — at least once per month — you are in trouble. If you go to your doctor on an erratic and unplanned basis, then you are also in trouble. The insurance company will have legitimate grounds to deny your claim.
What you can do about it: Don’t miss any appointments with your doctor. Make sure your prescription medications are monitored. Insist that your doctor schedules appointments on a regular basis. This could mean every two weeks or every month.
Reason 2: You are not being treated or seen by a psychiatrist
Psychiatrists are specialists in treating mental illness. It can be a red flag for the insurer if you are claiming to be disabled by mental illness but haven’t seen a psychiatrist.
This isn’t always true. Most mental health claims can be managed by your family doctor alone. However, if that isn’t working, you should talk to your doctor about seeing a psychiatrist.
If you don’t need ongoing treatment from a psychiatrist, at the very least, you should have a psychiatrist consult in your treatment plan. If you haven’t seen a psychiatrist, and there is no plan for you to do so, you will likely get cut off. The insurance company will say your depression or anxiety can’t be that bad if you aren’t seeing a psychiatrist.
If your mental health doesn’t improve, the insurance company will cite the failure to see a psychiatrist as a reason for denial of benefits. The one exception to this is if your family doctor demonstrates they are providing a very high standard of care in the management of your mental illness. This is extremely rare, however.
What you can do about it: Ask your doctor to refer you to a psychiatrist for a consultation. If you are on a waitlist to see a psychiatrist, try to get an appointment as fast as possible. One way to do this is to ask them to call you if there are any cancellations.
Reason 3: You are not attending the recommended psychological treatment
A combination of medications and psychological treatment is usually the best practice for the treatment of mental illness.
If any of your doctors recommend that you see a psychologist, then you absolutely have to do it. Failure to attend recommended treatment with a psychologist or attending and giving a half-hearted effort will guarantee a denial of your disability claim for mental illness.
People give me a hundred different reasons why they didn’t go for the recommended psychological treatment. Let me be blunt: Excuses don’t matter. You don’t believe it will work? Doesn’t matter. You can’t afford to see a private psychologist? Get on the waiting list for treatment from your local hospital or mental health outpatient centre. You don’t want to sign their forms? Ask for reasonable changes to the forms and sign them anyway.
If your goal is to get well again and to have your disability claim approved, then you absolutely have to attend any recommended psychological treatment and give 100% effort. If you don’t get psychological treatment, the insurance company will deny your claim, no matter how legitimate you think your excuse is.
What you can do: Don’t make excuses. Find a way to receive the recommended psychological treatment and put 100% effort into it. If you can’t afford a private psychologist, get referred to a hospital or clinic outpatient program. These will be covered by Medicare.
Reason 4: Your doctors and psychologists are providing a poor standard of care
Even if you are attending treatment, the insurer can deny your disability claim if the care is substandard.
Getting below standard care is primarily out of your control, but if your treatment providers are not following best practices for the treatment of your mental illness, then there is a good chance the insurance company will deny your claim.
Insurers have their behind-the-scenes medical advisors who will carefully review the treatment you are getting. These behind-the-scenes medical reviewers are well-schooled in the best practices for the treatment of mental illness. They are experts at pointing out the deficiencies in what your doctors or psychologist is doing.
For example, a common example of poor standard of care is for your doctor to prescribe medication but then fail to monitor you carefully and make adjustments to the medication. Without careful monitoring, your mental health is unlikely to improve. This can lead to a situation where your claim will be denied, even though you are taking the prescribed medication.
What you can do about it: If you have any sense that your doctor is not following best practices, you should get a second opinion. This is why having a psychiatrist consult on your care is extremely important. While the expertise of family physicians can vary widely, most psychiatrists are well-versed in the best practices for the treatment of your condition.
Reason 5: Your treatment providers are not creating the proper documentation
From the disability benefits provider’s perspective, if something isn’t written in the medical charts and files, then it doesn’t exist.
Your treatment can be of the highest quality and best practices. Still, if your treatment providers haven’t documented it properly in the medical records, then in the eyes of the insurance company, you have not received quality care.
The reality of what is going on with your treatment doesn’t matter. What matters is what is documented in your medical files and records. At the end of the day, the insurer makes decisions based on the paperwork included in their claim file. You can be getting the best care in the world. However, if that care has not been recorded and documented correctly, it will not exist in the insurance company’s file. Without “accurate” medical records, there is a strong possibility that your claim will be declined for technical reasons.
What you can do about it: Point this problem out to your doctors. Have them write a narrative report that explains the treatment provided, your response to the treatment, how they have changed the treatment based on your response, and the plan going forward.
Final Thoughts
If you want to maximize your chances of winning disability payments for mental illness or to prevent your payments from being cut off, you need to be under the regular care of a family doctor who is following the best practices.
Ideally, you will also get treatment from a psychiatrist or at least have them consult on your care. You must attend psychological treatment (and give 100% effort). You should do your research — from credible sources — on the best practices for medical care for your mental illness. This will give you some idea of whether your doctors are following those best practices.
If your doctors are not meeting best practices, both in terms of treatment and in documenting your treatment, your benefits will be cut off at some point — even though you are disabled and unable to work.
In some situations, the insurer will deny your legitimate disability claim, even if you and your doctors do everything right. If that applies to you, you should seek legal advice immediately. The insurer is not acting reasonably, so engaging in future appeals on your own will have little chance of success.
Resolute Legal has helped thousands of Canadians win mental health disability claims. We know why these claims get denied, and we know how to overturn them. Our lawyers represent people in claims involving short-term disability, long-term disability, CPP disability, workers’ compensation, employment disputes, and the disability tax credit.
We have offices in Toronto, Ottawa, Moncton, and Halifax, serving clients in every province except Quebec. Most of our services, about 90%, are online, and we will visit you in person if necessary. For more information, check the pages below:
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