Over the years, we’ve had the privilege to represent clients struggling with mental health issues that prevent their ability to perform the material duties of their own occupation. Sometimes, these conditions also become so severe that they prevent the performance of the material duties of any occupation to which they are reasonably suited based upon their age, education, and experience.
Bipolar disorder, anxiety disorder, depression, and schizoaffective disorders cause severe and debilitating impairments in functioning. According to the National Institute of Mental Health, one in five adults in the United States experience mental illness (57.8 million in 2021). One in five means a fair estimate is that 20% of the United States population experiences and struggles with mental health issues. We also seem to all be seeing an increase in problems associated with mental health for various age groups and populations across our society. Thankfully, the stigma associated with mental illness and the misunderstanding of what this means seems to be going away in certain sectors of society; in others, not so much.
As many have said, there is so much misunderstanding because we don’t see a mental health issue like we see a physical injury. We see no broken bones and no bleeding; however, for the person struggling with a mental health issue, the problems are just as real and just as severe. For these people, while they may have worked for years and been productive, sometimes things happen and their mental health issues becomes an impediment to their ability to maintain employment by performing those duties required of them.
When this happens, disability insurance is often there and is intended to be a means to supplement income while the mental health issue is addressed. Unfortunately, disability insurance companies don’t always play by the rules and people with deserving claims are denied. All disabled workers struggle in these times. For the disabled employee struggling with a mental health problem, the denial of a disability insurance claim may feel overwhelming. This is one reason why we find it so rewarding when we can help people with a mental health issue overcome a disability insurance denial, prevail, and show that they were truthful all along when they reported their claim.
Good and Bad Days
Often, we have found these clients have good and bad days. These clients are able to meet demands and function well at times. However, at other times they experience such debilitating symptoms from their mental health disorder that they cannot leave their home without risking a hospitalization. Decompensation generally describes when, due to mental health problems, a person is triggered into a state of distress where they cannot meet even the basic demands of activities of daily living. Stress and certain triggering stimuli can cause this to happen. This makes it even more difficult for the person struggling with a mental health issue to function in the workplace.
Medications prescribed by treating physicians certainly can help. However, these clients often find themselves stuck between a rock and a hard place. If they take the prescribed medications, then they may avoid the most debilitating symptoms associated with their mental health issue and avoid decompensating. However, if they take their prescribed medication then the known side effects cause further impairment in their ability to consistently perform job tasks. This puts the individual in some cases in a perpetual back and forth between struggling with their severe, medically determined symptoms or struggling with the side effects from medication that cause further problems with functioning and performance, either at home, in the workplace, or both. They want to comply with the doctor’s recommendations. They also want to work if they can. Sometimes, both can’t be done at the same time and a disability insurance claim is made.
Medications and Side Effects
Some medications prescribed for mental conditions cause drowsiness and sedation. These known side effects impair the clients’ ability to consistently perform job duties. For instance, antipsychotics such as Clozaril and Seroquel may cause drowsiness. Tricyclic antidepressants such as Amitriptyline, Amoxapine, Desipramine (Norpramin), Doxepin, Imipramine (Tofranil), Nortriptyline (Pamelor), Protriptyline, and Trimipramine have known possible side effects of drowsiness, dizziness, blurred vision, and others. The literature tells us that the potential for people to experience these side effects varies from person to person. Because of this, we find that some clients have difficulty getting across to decision makers (claims adjusters and others) that they truly are experiencing debilitating sedation or other problems when they take their meds, but that they must take their meds if they want to follow their doctor’s advice and ward off other intrusive thoughts and feelings associated with their medically diagnosed mental disorder.
Some decision makers rely on what they know from their personal experiences, or other cases. This isn’t fair to the claimant in a disability insurance claim because each person is unique. Some people may experience some mild side effects, others moderate, others more severe. There is no one-size fits-all-approach to analyzing these cases, and close attention must be paid to the medical records and the reports of the claimant making a claim under a disability insurance policy for mental health reasons.
Side effects from prescribed medications may result in unscheduled work breaks and absences. Unscheduled work breaks and absences are only tolerated for a certain period of time by even the most forgiving of employers. Unfortunately, other employers do not understand the significance and debilitating nature of clinically diagnosed mental disorders.
Mental Health and Disability Insurance
Disability insurance provided by employers extends in most cases to cover not only physical but also mental conditions that result in impairment and inability to perform job duties. Sometime, an employee commences employment with a diagnosed mental condition that is well-controlled and that does not prevent the performance of their job duties. These clients (for various reasons) then find themselves later in a compromised state, whether due to outside influences beyond their control or exacerbation of their underlying mental condition.
Making the Disability Insurance Claim before Termination or Separation
If they are a beneficiary under an insurance policy purchased by their employer, their claim is often covered by the Employee Retirement Income Security Act (“ERISA”). Their claim for short-term disability must initially be made before a separation or termination of the employment relationship. Otherwise, this employee will no longer be covered under the employer’s disability plan if they subsequently make a claim for short-term or long-term disability insurance coverage.
Unfortunately, we have had several consultations before where the claim that the potential client had for disability insurance coverage due to a mental disorder, such as bipolar disorder, anxiety, disorder, depression, or schizoaffective disorder, would have been a winning claim and deserving of approval by the insurance company but was not timely made.
Unbeknownst to the potential client, they no longer had disability insurance coverage and had not yet made a claim before they were terminated. In such a case, we could not make the claim either directly to the disability insurance company or through filing a lawsuit with success simply because the potential client no longer had disability insurance coverage. We expect that in only the rarest cases that is it ever explained to the employee that they would no longer have disability insurance coverage for a policy that they contributed at least some of their hard-earned work earnings to simply because they could no longer work due to a mental condition and had not made the claim before they were let go.
We sympathize with these people and have always wished we could have assisted them with their claim for disability insurance coverage before they lost the opportunity due to termination or separation. If the claim had simply been made, then they would have preserved their right to pursue these benefits that replace at least a portion of their income with disability insurance before they were terminated. If the claim had been properly made and then denied, the opportunity to appeal and supplement the administrative record would still be a viable option. If the disability insurance company continued to deny, these people would have the opportunity to file a lawsuit to pursue their right to disability insurance benefits under the policy.
The moral of the story is that it’s always the safest bet if you are suffering from bipolar disorder, anxiety, disorder, depression, schizoaffective disorder, or any of the various medically recognized and diagnosed forms of mental disorders that commonly affect Americans every day to file your disability insurance claim appropriately before you are terminated, or you voluntarily separate from your employer. Then there is at least a chance at obtaining disability insurance benefits and income replacement. Medical records and doctors’ opinions may then demonstrate an inability to perform the material duties of your own occupation and short-term disability insurance benefits may be available.
Likewise, once someone proceeds through the short-term disability timeframe set forth in the disability insurance policy and if they continue to experience debilitating symptoms arising from a mental disorder, then they may have the right to obtain long-term disability benefits through the disability insurance company (of course, this is all dependent on how the policy is written and the terms found in it).
Evidence to Support the Mental Disorder Disability Insurance Claim: Medical Records
Working with your doctors is always the first and foremost step in addressing a mental health disorder. Thankfully, healthcare professionals have tools today, both through prescription medications, therapy, and otherwise, to assist patients struggling with their mental healthcare. Also, it will be the medical records generated through this mental healthcare that will be the core evidence for the potential client to rely on – and the lawyer to utilize – in prosecuting the disability insurance claim.
Evidence to Support the Mental Disorder Disability Insurance Claim: Opinion Letters and Questionnaires
Opinion letters can also be persuasive and assist the claimant in explaining just how debilitating their mental health disorder really is. We can’t count the number of times we’ve heard something along the lines of “My doctor says I am disabled. Why doesn’t the disability insurance company understand?”
What many people don’t know is that a decision that a person is disabled is both a medical and a vocational decision. For the mental disorder claimant, a psychiatrist, psychologist, or other qualified healthcare provider may be able to give an opinion within all reasonable medical probability on how the diagnosed condition will impact the person’s ability to perform certain tasks, from both an exertional and non-exertional standpoint.
An opinion letter – or a questionnaire – provided by the treating psychiatrist or psychologist may help explain just how debilitating the person’s condition really is. Disability insurance companies may not be required to automatically follow the opinions and recommendations of a treating healthcare provider. However, an opinion letter or questionnaire completed by a psychiatrist or psychologist can go a long way in adding weight to the argument that the client’s assertions that she cannot work due to her depression, anxiety, schizoaffective disorder, or other diagnosed mental health disorder are not only well founded, but that she meets the definition of “disabled” in accordance with the disability insurance policy. Also, a treating psychiatrist or psychologist can give an opinion to corroborate the client’s subjective complaints regarding the side effects of a prescribed medication.
Evidence to Support the Mental Disorder Disability Insurance Claim: Neuropsychological Evaluations
Neuropsychological evaluations are a form of testing performed by qualified healthcare professionals. These include surveys and questionnaires completed by the person being evaluated as well as subsequent testing. Some examples include writing, drawing, solving puzzles, answering questions, and responding to inquiries. The healthcare provider then scores and interprets the results from the testing. Neuropsychological testing may be beneficial for the claimant in a disability insurance claim suffering from emotional disturbances. However, neuropsychological testing and evaluation is often applied in cases involving traumatic brain injury (“TBI”), stroke, and neurodegenerative disorders.
A person who sustained a head injury may have a TBI and neuropsychological testing may reveal the extent to which the TBI has impacted functioning. Likewise, neuropsychological evaluations may reveal the extent to which a person suffering from Alzheimer’s disease or Parkinson’s disease experiences limitations in their exertional and non-exertional capacity.
Evidence to Support the Mental Disorder Disability Insurance Claim: Vocational Assessments
Vocational assessments are performed by vocational experts and consist of an evaluation of the person’s education, background, and skills. A vocational profile is created to explain the person’s job history, occupational requirements, and what skills they have gained along the way and whether those skills are relevant and transferrable to other work. Vocational assessments work in conjunction with the opinions from healthcare providers to complete the picture for the claimant struggling with a mental health disorder. Not every case warrants or needs a vocational assessment; however, this is another tool that may assist in prevailing in a disability insurance claim or in reversing a disability insurance denial.
The mental health disability claim presents unique obstacles. Every claimant benefits if they have someone to assist them in putting together the necessary documents and proof required. Those struggling with mental health issues are often faced with some of the most difficult times as claimants in disability insurance claims. We always welcome the involvement, with permission, of family members and friends as willing participants in the process to obtain disability insurance benefits for their loved one.
When the disability insurance case is governed by ERISA, it’s imperative that the record is built during the administrative appeal to show that the claimant meets the criteria set forth under the disability insurance policy (often referred to as a plan) defining what it means to be “disabled.“ Gathering of medical records, attending appointments, and keeping the faith can often feel like a mountain too high to climb.
When this is the case, a disability attorney may be a helpful partner to navigate the disability insurance process and attempt to secure a favorable decision during the administrative appeal. Of course, once administrative remedies with the disability insurance company are exhausted, the claim then is ripe for the filing of a lawsuit. If governed by ERISA, the lawsuit should be filed in the federal district court that has jurisdiction over the plan administrator; otherwise, and in most cases an insurance company who decides the disability insurance claim during the administrative appeal. Once the lawsuit is filed, the federal rules of civil procedure govern the handling of the matter before the United States District Court, and attorneys for the insurance company who handled the administrative appeal will answer. They will deny the claims made in the lawsuit as a matter of course.
One good thing among others about these cases that fall under federal law is that the defendants cannot merely file a general denial. Instead, the lawyers for the disability insurance company must specifically deny those allegations made in the lawsuit. As you see the process unfold, it becomes clear how the work done during the administrative appeal for a claimant struggling with mental health issues is critical to ensure a successful outcome. There are a few days better than the day when counsel for a disabled claimant may contact the client to inform them that a favorable decision was reached or that the claim may be resolved on terms they find agreeable.
If you or a loved one need assistance in navigating a disability insurance claim due to a mental disorder and its impact on your or your loved one’s ability to work, please consider contacting us at DFW Disability Lawyer. We would be honored to discuss your case with you.