Assessments involve physicians, health-care providers, employees and employers
Dealing with a disability claim is no easy task, and insurers play a key role in serving as a touchpoint for employers, employees, physicians and health-care providers.
From the initial claim forms to return-to-work facilitation, an insurer will have contact with an employee’s physician, treating specialist, nurse practitioner, physiotherapist, psychologist or other treating health-care practitioners at multiple stages of a work absence.
Whether it is a short-term or a long-term disability claim, there are multiple points during the assessment and ongoing management of a claim when an insurer will require medical information. To thoroughly assess and manage a claim, it’s essential to have medical evidence provided on claim forms, in specialized reports or through customized letters.
Canadian life and health insurance companies recognize the administrative burden such requests can place on family physicians and other primary health-care providers.
To help minimize the time and effort required, the Canadian Life and Health Insurance Association (CLHIA) developed standard medical request forms that can be used throughout the disability claim life cycle.
Attending physician statements
When submitting a claim for short-term disability benefits to an insurer, there is an Attending Physician Statement (APS) that requests details of the employee’s medical condition.
The disabled employee is responsible for having the form completed.
Depending on the nature of the condition, the form could be completed by the family physician, a treating specialist or another primary health-care provider such as a nurse practitioner.
Some of these forms are short and concise and if the work absence is of very short duration, only a few lines on the first page need to be completed.
Once an employee has been off work for an extended time, a long-term disability claim may be contemplated.
To gather the pertinent medical details needed for such a claim assessment, a standard APS is also available, capturing the initial evidence to support a medical absence from work.
Many insurers have a suite of disease-specific forms available. Later this year, the CLHIA will release a standard Mental Health Condition Questionnaire developed with help from the Canadian Psychiatric Association and industry experts.
In many instances, the most informative details a case manager gathers are from the disabled employees themselves, such as information about the medical condition, the treatment plan, response to therapy, return-to-work goals and non-medical factors affecting an employee’s circumstances.
In some cases, a case manager may call the primary health-care or treatment providers to clarify information and expedite the assessment process.
At times when more detailed medical information is required, a case manager may send a condition-specific letter or medical questionnaire to a health-care provider. The written request is customized so the questions are specific to the employee’s situation and to the point in time of the file review.
To obtain medical records of any kind, employees must provide written consent for the release of information to an insurer.
It is important to know that consent forms are customized for specific purposes, such as assessing a disability claim. They are also time-limited, so signed consent forms are renewed from time to time.
It is not uncommon for insurers to require updated consent forms every calendar year.
It is important for employees to know that if they are off work due to a medical condition, their employer is not entitled to any of the medical details contained in their claims file.
This includes the diagnosis, symptoms the employee is experiencing, the nature of the treatment for the condition or the names or specialties of their treating doctors.
Although medical evidence is required as part of the disability claim submission, medical forms can be sent directly to the insurer after being completed by the health-care provider.
Any medical information an insurer requests or receives regarding a disability claim is treated confidentially.
An employer, an employee’s supervisor, a co-worker — even the disabled employee’s family members — are not privy to any of the medical details within the insurer’s file.
However, in rare circumstances, an employer may be informed of serious situations such as a highly communicable disease that may put other employees at risk. Under these circumstances, the employer would be required to take the necessary precautions to protect others in the workplace.
Although an employer does not have the right to know a disabled employee’s medical diagnosis, a case manager can advise employers of an employee’s restrictions and limitations as it relates to his ability to perform his job.
Since it is the employer’s duty to accommodate the disabled employee when he returns to work, the employer is entitled to information that will help facilitate the accommodations required, such as the need for special equipment, the need for and timing of breaks, and supportive measures that may be required from supervisors and co-workers.
The case manager co-ordinates a return-to-work plan with all stakeholders — the employee, employer and health-care provider — to ensure realistic and attainable return-to-work goals are set. When setbacks arise, the case manager manages the plan with the employee’s state of health and privacy in mind.
Claims don’t always run smoothly. Sometimes they are denied and must be appealed, meaning more information is required to make them approvable. Some claims can be appealed several times without ultimately being approved, while others are approved with the benefit of new information. Often, there are legitimate reasons for declining a claim, such as policy exclusions or provisions that limit benefits.
It is important to know, however, that there are places to go if an insurer’s decision is not acceptable to an employee. For instance, every insurer has an ombudsman who manages complaints. Employees should be encouraged to escalate concerns to the insurance company ombudsman if they feel their claim has been managed unjustly. Beyond this, there is also an OmbudService for Life and Health Insurance (OLHI) that helps consumers manage complaints.
Lastly, it is important to note that disability claims are not immune to fraud. This doesn’t mean fraudulent claims are regular but they do exist. Employers, employees, health-care providers and case managers all have a responsibility when it comes to submitting and managing legitimate claims. In the long run, fraud costs everyone.
Laurie Down is director of disability policy at the non-profit Canadian Life and Health Insurance Association. For more information about the CLHIA or OLHI go to www.clhia.ca or www.olhi.ca.
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