Bodily Injury Claims: Study 6
Psychological Disorders; Disability
Traumatic Neurosis:
Nervous disorder caused by a traumatic event
Manifests itself in the emotional, psychological, and physical health of the claimant
Claimant is less successful coping with everyday living
Symptoms include:
Tranquilizers are used as medication
Psychotherapy is another form of treatment used
Certain conditions make a claimant vulnerable to traumatic neurosis:
Adjuster must establish whether illness relates directly to a previous condition or was caused or worsened by the accident.
Depression:
After traumatic event a natural symptom of the event is depression
Often expressed as feelings of sadness, grief, helplessness, and emptiness
Depression is also a diagnosis of a mental disorder
Commonly diagnosed condition is major depressive disorder
Symptoms of a diagnosed depression disorder include:
Treatment involves medication and psychotherapy
Diagnosis of depression must be linked directly to the accident to be compensable
Post-Traumatic Stress Disorder:
DSM-IV relied on to diagnose this condition
PTSD is an anxiety disorder caused by experiencing a distressingly serious event to oneself or someone close to oneself
Symptoms include:
Response of intense fear, helplessness or horror
Recurrent intrusive re-experiencing of the traumatic event in the form of:
Avoidance of stimuli associated with trauma and some numbing of general responsiveness
Persistent symptoms of arousal (could be associated with hypersensitivity)
Disturbance must have lasted for more than one month
Significant clinical impairment in important areas of functioning
Diagnosis
of PTSD will make it easier for claimant to proceed with claim as it is
a recognized mental disorder specifically caused by a traumatic event
Immediate crisis counseling is effective treatment for PTSD
Phobias:
are unrealistic fears.
A phobia is an anxiety disorder that inhibits patients from engaging in a particular activity.
Responses from the patient are excessive or unreasonable given the circumstances.
Symptoms include sweating, heart palpitations, dizziness, or abdominal distress when faced with the triggering activity.
Psychologists treat this by guiding a patient to confront the fear (desensitization)
Psychosomatic Conditions:
Physical symptoms manifest themselves but emanate from a psychic, emotional or mental origin
Problem can be triggered by an injury
May stem from an imagined injury
Difficult to diagnose and treat
Symptoms are:
Symptoms may last for years
Factitious Disorder: refers to a patient who consciously fabricates symptoms to fulfill an unconscious need to be sick.
Typical profile of such patient includes:
History of many physical complaints, multiple hospitalizations
Inconsistent cooperation provided to the attending doctor
Acknowledgement that symptoms are controlled
Demonstrated dependency on attention provided by medical personnel
Thin line between a diagnosed factitious disorder and malingering
Motivation separates the two
Malingering must establish that the patient had conscious desire for financial gain
Factitious disorder there is an unconscious motivation to be sick
Possible Treatment for Mental Disorders:
Proof of Causation:
Adjusters must be satisfied that subjective complaints are related to the accident injury
Proof of causation is required to validate a claim
If
the claim is serious enough adjusters may suggest further testing to
substantiate subjective symptoms even though a doctor may not consider
it to be necessary from a medical point of view
Psychological Disorders:
Most psychological disorders come in the form of subjective complaints
Psychiatrists and psychologists base diagnoses largely on statements made by the patient
Results can be interpreted in different ways
Possible Fraud Warning Signals:
Prolonged recovery period from an earlier accident
Previous medical or disability claims
Work time lost due to previous soft tissue complaints
Poor general health (allergies, frequent doctor visits, work absences)
Treatment programs with many therapists treating the same condition
Only recently employed
Dissatisfaction with job
Spouse currently disabled from work
Unstable family situation
Diagnosis of malingering:
Justified
if it could be shown that the claimant was intentionally magnifying the
seriousness of the injury to deliberately extend the period of
disability or otherwise experience financial gain
Basis which diagnosis is founded must be reviewed:
What series of tests were administered?
What other assessments were made?
What were the physical objective findings that support the diagnosis?
Have the results of surveillance, activity checks and interviews with the neighbors been considered?
It
is easier to suggest that a claimant is a malingerer if there is a
history of dishonest acts and there exists a tangible (financial) motive
for consciously feigning illness
Evaluation of a Diagnosis of Malingering:
Review:
Credentials and competence of doctor
Claimant history
Medical
Employment
Social
Adjuster’s investigation
Surveillance
Activities check
Interviews
Tests administered
Other assessments completed
Objective findings
Motive established
Other possible conclusions dispelled
It
is important that the adjuster keep an open mind in these situations,
conduct the necessary investigation, and come to a reasonable conclusion
based on available proof.
Classifying Disabilities:
In
insurance disability refers to the inability to engage in any gainful
activity because of physical or mental impairment which can be expected
to last or has lasted for a continuous period
Disability prognosis predicts how long it will be before the claimant returns to work, not an exact science
Based
on the doctor’s personal experience with the type of injury, patient’s
age, occupation, mental outlook and the injury itself are factored in
Types of Disability:
Temporary partial disability:
means that the claimant is temporarily unable to perform some
job-related tasks. Often symptoms such as fatigue or pain do not permit
the claimant to work a full day for a time
Temporary total disability: means that the claimant cannot perform any job duties for a specific period of time
Permanent partial disability:
means that a permanent loss of a body function has occurred. In some
cases jobs can be modified to minimize the effects of the lost function.
It also applies to the loss of a part of the body – an eye, hand or
foot
Permanent total disability:
means that the claimant is permanently and totally incapable of
performing any job functions. A severed spinal cord is usually
classified as a permanent totally disabling injury.
Returning the claimant to work:
For many claimants psychological benefits of returning to work can be tremendous
Wage loss claims require careful analysis of medical reports
It
must be determined whether the time lost is appropriate considering the
type of injury, the occupation and the duties of the injured person
Even though a claimant is disabled it may not affect his or her job functions
An office worker might be able to perform all work-related duties even with a broken leg
On the other hand, a construction worker might be totally disabled with the same injury.
It
is important to know the claimant’s age, medical history, type of
accident, job-related duties and leisure activities, particularly if
they are unusual. This is background information.
Contact
and follow-up with the claimant are vitally important to this aspect of
the claim. Adjusters must take an active role to conclude a case.
Factors Affecting Period of Disability:
Health: Persons in good health will generally recover more rapidly
Age: Younger persons may heal more quickly than older persons under certain circumstances
Pre existing Condition: Can make the injury more severe or hinder recovery.
Injury Severity:
Complications of infection, muscle involvement, tendon or nerve
involvement can prolong a disability period. A fracture which extends
into a joint or a laceration which severs or damages a nerve or tendon
will extend the disability period.
Infection: An infected wound can slow recovery and lengthen the disability period.
Psychological Attitudes:
Thinking patterns can impede or improve the healing process.
Occasionally a permanent disability will develop based on a
psychological condition.
Occupation: If a job has demanding physical and mental standards of performance this may increase disability time
Environment: A person’s home environment may either lengthen or accelerate healing times.
See “Whiplash” charts on pg. 11-12
Definitions:
Diagnostic and Statistical Manual IV (DSM-IV): The
most widely used reference source to describe mental conditions and
disorders. It lists diagnostic criteria that are generally accepted as
the standard for psychological disorders.
Neurosis: is a disorder of the thought process without any sign of disease of the nervous system
Reactive Depression: is depression brought on by losses incurred in an accident or by the stress of being involved in an accident
Post-Traumatic Stress Disorder:
is characterized by persistent re-experiencing of a very stressful
event. Anxiety symptoms and avoidance behavior are commonly present.
There is controversy within the medical community concerning the
diagnosis of this illness.
Psychosomatic: refers to the relationship between the mind and the body.
Somatoform: means the patient’s symptoms are psychogenic in origin but resemble those of physical disease.
Somatization: refers to the conversion of mental experiences or states into bodily symptoms.
Objective findings: are detectable by an observer or an external measure.
Subjective findings: are not detectable by or through the senses of an observer. Symptoms verbally reported by the claimant are relied upon.
Malingering:
is the willful, deliberate, and fraudulent feigning or exaggeration of
the symptoms of illness or injury, done for the purpose of a consciously
desired end.
World Health Organization (WHO) Definitions:
Impairment:
is the loss or abnormality of physiological or psychological function
or anatomical structure; example – amputation or paralysis
Disability: is the restriction or lack of ability to perform within a normal range; example – loss of ability to write with the hand.
Handicap:
is an environmental or social barrier that impedes individuals with
impairments or disabilities; example – an employer does not provide an
alternative to writing by hand.
Disability Period:
is the time interval in which a person is unable to engage in any
substantial gainful activity because of a physical or mental impairment.
The activity could be business employment, pursuing an education, or
other duties.
The Canadian Classification and Dictionary of Occupation (CCDO) manual describes:
Sedentary Work:
requires lifting up to 10 lbs. It mostly involves sitting, however,
occasionally walking and standing are necessary to carry out some
duties.
Light Work:
requires lifting of up to 20 lbs. and carrying objects frequently of up
to 10 lbs. This job requires significant walking or standing. It also
includes situations which involve sitting most of the time with pushing
and pulling of arm or leg controls.
Medium Work:
requires frequent lifting of up to 50 lbs. and carrying objects
weighing up to 20 lbs. Even if the job involves sitting a significant
part of the time it may qualify for this category if pushing and pulling
of arm or leg controls is necessary.
Heavy Work: requires lifting of up to 100 lbs. and carrying objects weighing up to 50 lbs.
Very Heavy Work: requires lifting of up to 100 lbs. and carrying objects weighing up to 100 lbs.
Compensation Neurosis:
has been coined to describe the claimant who is able to return to a
pre-accident condition once the claim is settled. Financial incentives
fuel the claimant’s symptoms.
Waddell Test: is a psychological test sometimes used to corroborate a diagnosis or to detect exaggerated or inappropriate responses
