People tend to panic when their medical leave application gets denied by their insurance company.
In my experience, a primary reason that people’s claims get denied is because their applications, which their physicians’ submit, are incomplete. An insurance company has every right to deny claims that are incomplete. Universities don’t admit students that submit incomplete applications. Companies don’t hire individuals that don’t fully complete application forms, too. Why shouldn’t insurance companies?
If you have been denied medical leave, I strongly suggest that you not panic. Instead, ask your physician to give you a copy of the application form they filled out on your behalf. Review this form, and see whether any blanks have been left incomplete. Also, look to see whether any blanks have been completed incorrectly.
Looking for incorrect information on the form will be more difficult for you than looking for blanks. This is largely because most people don’t utilize the technical language that the forms require.
The most common error I find on the forms when I review them for people is that the section that asks for a psychiatric diagnosis has not been filled in, or has been filled in incorrectly. If the form asks for a diagnosis, this means a diagnosis is required. Frequently, the information contained in this section of the form is informative, and is in the ball park, but is not a diagnosis. Makes sense?
When I suggest to a client that they go on medical leave, I usually caution them that their application may be denied by their insurance company. I do this so that they don’t panic if this happens. I also do it because this experience is so common that I want them to be prepared when and if it happens to them.
So what should you do if your medical leave application has been denied? First, I suggest that you remain calm (which can be difficult to do). Ask your physician for a copy of the application that they submitted for you, and bring it to a psychologist that has experience working with the forms. Ask the psychologist whether they have experience appealing an insurance company’s decisions, because many of us do. Once you have found a psychologist that can help you, I suggest you bring them the completed form and ask them to review it.
I often approach insurance companies, with my client’s permission, to ask why the client’s application has been denied. I work cooperatively with the insurance company. Often, I will write a letter to the company on my letterhead on the client’s behalf. In the letter, I include a “Current Psychological Diagnosis” for the client.
(You can use the terms “psychiatric diagnosis” and “psychological diagnosis” interchangeably for the most part. I changed terms because the words “psychiatric diagnosis” is what an insurance company asks for, while a “psychological diagnosis” is what a psychologist provides.)
I have to complete a “Psychological Assessment” with the client before I can provide a current psychological diagnosis, which means I have to talk for about an hour with the client to ensure that I understand their personal history and their current situation, and so that I can make a psychological diagnosis.
I will often write a letter to the insurance company, detailing the client’s situation in more detail than can fit on a form (because the spaces on the form are itsy bitsy), when this is appropriate to do. Often this is enough, and the client’s claim gets approved by the insurance company.
On a significant number of occasions, however, this is not enough and the appeal gets rejected. Experience has told me that we can still be successful, however, if we hang in there and try again. At this point in the process, trying again is called a “second appeal.” I suggest that my clients not panic when we get to this stage. It just means we will need to provide more information and that I will need to talk to more people.
During the second appeal, a psychiatrist is often the professional that reviews the case. They will ask for additional information. Sometimes they want to know why the person hasn’t been prescribed a psychotropic medication such as an antidepressant (which sometimes they have been, but they don’t want to take), or why they haven’t seen a psychiatrist (which may be because they are on a wait list).
Whatever the case, it is important to maintain an open, cooperative communication-style with the insurance company. It’s okay to cry and to share frustration. It’s okay to talk about how you are struggling psychologically, if this is the case as well
Above all else, I suggest that you remain cooperative, and that you bring in a knowledgeable professional such as a psychologist, to advocate for you on your behalf. You may be tempted to ask your physician or a psychiatrist to act in the role of advocate, but these professionals are usually too busy, and have too much paperwork in front of them, to give your case the time and attention that will be required to submit a successful appeal (or second appeal) on your behalf.
I hope the content of this blog post is helpful if you find yourself, or a family member, in the appeal process.
Dr. Patricia Turner, PhD, RPsych
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