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There is an ongoing focus on mental health claims crossing all continents and Life/Health products, and this has only intensified as a result of the COVID‑19 pandemic. A potential explanation for this development may be that the number of mental health diagnoses has objectively changed within the last years.
Current evidence is indicating an increasing number of mental health diagnoses and sick leave absences due to mental health diagnoses, particularly the diagnosis of depression. Experts largely agree that it is not the disorder itself that occurs more frequently, but that the diagnosis is made more often than in the past. Various causes for this development are currently being discussed.1
One of the possible causes for the increase could be that the diagnosis of depression is, in some cases, not evaluated accurately. Official diagnostic criteria required by professional societies, such as the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM‑5), are often not met, or the diagnosis is based only on subjective, self-reported information.
Additionally, in a significant number of cases, diagnoses are made without an appropriate specialist assessment, e.g. by a physician not qualified for diagnosing and treating mental health disorders. At times for example, the presence of mood swings in reaction to a stressful situation in a patient’s life leads to a quick but unsubstantiated diagnosis.
The situation is made more complicated because the clinical picture of a depressive episode is subjective in nature. Unlike physical disorders where one may be able to point to an imaging study, laboratory test or diagnostic parameter, detailed objective evidence on the clinical picture of depression is often missing when assessing depression claims.
In summary, the insurance industry must address three main aspects in the assessment of depression claims:
Considering the above complexities, it may be challenging for claims assessors to find the right balance between efficient, supportive customer service and a robust risk assessment supported by sufficiently detailed claim evidence. Insurers want to avoid unnecessary delays in the decision-making process. On the other hand, adequate medical information is needed for fair and evidence-based decision-making and a robust risk assessment.
Gen Re has been providing its clients with professional support in the field of mental health for many years through live and online training, e‑learning platforms, publications, and direct claims expertise and support. As a continuation of our existing comprehensive mental health services, Gen Re is excited to announce the launch of the Depression Claims Wizard – a new digital tool designed to assist claims assessors in deepening their understanding of depression claims.
The tool is designed to support disability claims assessors in their daily work while working on depression claims. It deepens an assessor’s understanding of depression and its impact on function by providing a detailed overview of the clinical aspects of the claimed condition, namely the case-specific symptoms, diagnosis, and treatment.
It helps identify the most important clinical aspects of claim decision-making, keeping in mind the functional status of an individual is only one aspect of the claim decision. Potential medical inconsistencies are also identified and the validity of the reporting source is evaluated.
If reliable information is lacking, the claims assessor is provided with additional evidence requirements. The wizard also guides the user to evaluate non-medical risk factors that may be driving the claim and provides useful recommendations for understanding the insured’s functional status.
Additionally, comprehensive best-practice guidelines are provided within the tool. These can be used by the claim assessor to further their knowledge and insight of depression claims.
Each disability claim is unique and must be assessed on its own merits, evaluating the medical, occupational, and financial circumstances within the policy terms and conditions. The focus of the Depression Claims Wizard is on the medical information. Most importantly, the digital tool does not take the decision away from the claims assessor and cannot replace or provide an opinion on the claim’s overall validity.
By providing the claims assessor with useful, evidence-based information related to the clinical picture of depression, users are empowered to make a valid assessment of whether clinical depression is likely to be present in the individual case, whether the diagnosis and reported symptom severity is sufficiently supported by objective evidence, and whether the prescribed treatment is appropriate, all while considering the impact of non-medical risk factors that may be driving the claim.
Gen Re is passionate about sharing our mental health expertise with our clients. We believe the Depression Claims Wizard is a unique and helpful addition to any claims assessor’s toolkit, allowing them to manage depression claims with confidence.
If you would like to know more about how you can incorporate this tool into your claims process, please contact your local Gen Re representative.
The information provided in the Depression Claims Wizard may assist in giving insight into the diagnosis and treatment of depression and can be used as training tool as well as general assistance in the assessment of claims. Gen Re does not guarantee the accuracy, completeness or currency of the information. The information is not intended as legal advice and can neither replace any such legal advice nor the claims assessment of the responsible claims manager.
