Sympathetically navigating the mental health claim conundrum

22 August 2018
| By Industry |
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A Super Review roundtable has found that while insurance companies and superannuation trustees are becoming more attuned to the complexities of dealing with mental health claims, changing practice and culture remains a work in progress.
Roundtable participants:
  • Mike Taylor (MT) - managing editor, Super Review
  • Col Fullagar (CF) - principal, Integrity Resolutions
  • Suzanne Smith (SS) - chief customer officer, MLC Life
  • Jenny Coleman (JC) - Trustee Advice Partner, NULIS
  • Emma Brodie (EB) - Senior manager, Qantas Super
  • Dr John Aloizos (JA) - Best Doctors
  • Lena Kesoglou (LK) - manager, wellness and recovery, MLC Life
MT So, I thought we’d kick off with, “Why does mental health represent such a particular challenge for insurers?” Is it an underwriting issue? Is there some other factor which makes it such a challenge? Actually, Suzanne, I thought we’d kick off with you, on that.
SS Sure. So, I think it represents a challenge, partly because of just how large a proportion of our claims experience is now represented by mental health claims. I think it’s something around 25 per cent to 27 per cent of claims coming through are mental health. Whether that be the primary cause of the claim – and, importantly, the secondary part of the claim.
Often, something starts as something simple and Col mentioned earlier someone with a broken leg ends up with a depressive disorder. We’re seeing mental health manifest in a lot of different ways. I think what that’s saying is, the way insurers have thought about claims, now, needs to be different to what we necessarily did in the past, because it is dealing with people that may not – maybe it’s one of the worst things that’s happened to them in their life. They may not be thinking clearly. They may not find the process straightforward. It may mean that they’ve got to slow down or do different things. So, I think, if we are just trying to treat it very mechanically, we won’t get the best results for people. 
And so, starting to think about how we bring mental health experts into our business, to actually deal with people, is really important. I think, trying to really think about the way that – what we’re asking of people, when we’re asking them to fill out complex forms, and getting people to tell their story in a way that represents what’s happening to them and what they need at a particular time – means that we’ve got to be more supportive in the way that we operate.
MT From the point of view of a super fund executive, it is a challenge, I guess. The fund has a responsibility to its members, to deal with claims and push things through where it thinks it should. How challenging is it, where mental health is concerned?
EB Yes – I was going to say to one of Suzanne’s points is, it really varies on the individual. So, you can have two people have the same thing happen to them – the same back injury. One will brush it off. They’ll be back to work within a few months. They’ll do everything they’re supposed to do and be fine. Whereas, the next person doing exactly the same thing, because of the mental aspect, will start sliding into a dark hole, in some cases, that is very hard to get out of.
They may actually have recovered from the physical injury, but they’ve then got the secondary psychological that makes it very hard to actually contemplate going back to work. So, I think that’s the difficulty. It’s so individual. You don’t know. You can’t just do a broad brush, “Oh, well, this is how you’re going to react. This is what’s going to happen.”
LK I was just thinking how – I think, as insurers, we like to follow process. And, when people follow some of those medical guides, you’ll say, “They’ve injured their knee. Let me look that up. What’s the diagnosis? What’s the treatment and what’s the expected recovery time? Here we go. By then, I’ll expect this.” And yet, in the mental health space, there’s no reliability around those guidelines that you’re given. They’ll sit there and say, “Depression. This timeframe to that timeframe.” When, really, it is so individual. I completely agree with you that there isn’t.
Even just the way we engage people has to be completely different in mental health. We have to have those options. One size doesn’t fit all, for everybody. And, I think, for insurers, what the challenge has been is to say – we understand that people may – it may manifest itself differently for each of them, but the way we need to interact with them is different, and that we need to be mindful of all of those things and be flexible enough in the way we interact with them. So, we’re cognisant of those differences of each person.
JC It lends itself more to a case-by-case interpretation, rather than a standard process, tick-box approach to doing the same thing every time. You’re less likely to be able to do the same thing every time. And, some of those processes are set up more for a physical condition and don’t accommodate a mental health condition. And, that’s not just for the member or the client. It’s also for the way we talk to the doctors, and the types of information that we’re trying to get from doctors when you’re assessing a claim. Not necessarily asking the right question, in the first place, doesn’t help you make the right decision.
CF Look, from my experience, there is a dearth of experience out there, in assessor-land. So, I don’t know that you’ve got enough people who are sufficiently experienced to handle the broken leg, the standard illness, and so on. And, that’s why they’re being driven from having a totally unrelated condition to ending up with a mental or nervous disorder, by virtue of the claims process.
So, until you have sufficient people to manage the fundamentals of claims, and how to deal with people just on a day-to-day basis, such that you avoid exacerbating their condition – until you get to that point, there’s no way on this Earth you’re going to have sufficient people who are experienced in handling something like mental and nervous disorders. They’re just going to be shooting arrows in the air and they’re going to be missing.
JC All claim types, you mean? 
CF Yeah. But, I agree with you entirely. Mental and nervous disorders are far more complex. I mean, I’ve got no clue, in theory, how to handle someone with a mental or nervous disorder. If I was trying to assess that person and work out whether they’re genuine or not – if I was an inexperienced assessor, I would struggle.
LK See, that term, “Are they genuine or not?” I really dislike that term. I was actually talking about it earlier, when we were talking in a completely different context. I don’t think our decision is about whether they’re genuine or not. I think we need to look at each person – of where they are. And, I think, if we approach each person saying, “Where is that person? What is actually going on?” and trying to get the crux of that – because, I deal with people who – if they think the insurer is going to question them or be suspicious of them, they start to exaggerate their behaviour. I think that’s normal, at least, of behaviour. And then, we start seeing all these inconsistencies. And so, we almost end up in this awful cycle of – sorry, I wasn’t challenging what you were saying.
CF No, no, no. Of course not. But, dislike it or not, the judgemental comes into it, and I see it day in, day out, where the assessor is, as far as I can see, forming a judgement. Now, if that’s the wrong way to approach it, so be it. But, I don’t know that they know any other way to approach it. And, you can sense it, sometimes – the way in which they’re going about the assessment or the claim. They do not believe that this person has got a problem. They think they’re having a lend of them.
LK We’ve tried to come a really long way of moving away from forms, processes, judgements – and, really having conversations with people. What we’re hoping is that that breaks down some of those previous negative approaches or perceptions. If you’re ready to speak to a person and get to the crux of what’s going on for them, you’re dealing with them, and working with that, and moving forward. I know we’re not, probably, as far along as we would like to be, in that area. But, I also wonder, too, that – even in that area, with mental health, you’ll get some people who don’t want to talk to you. And, that’s become, for some of our staff, at the moment – they’re saying, “Well, we want to talk to people. We know that’s the best way. Let’s engage with them.” And then, sometimes, people are so unwell that – 
CF Or, just do not trust the insurer.
LK They don’t trust you. And so, again, you need to look at how you’re supporting and engaging people, in that scenario, as well.
CF To be honest, I try to keep the insurance company as far away from the claim as possible.
LK Yeah, which is really sad to hear, Col, because I think that building trust is really critical. They have to deal with us. We have to deal with them. And, I’d rather us be in a scenario where they felt that they could be heard, that they were being heard, that it was a more positive relationship. And, I think that people like yourself, advisors, can play a real positive role in bridging some of that. Knowing that they’ve got that support – that they’ve got that advocacy there, behind them – if that’s what they feel they need, at that point in time, for that particular person – and build that bridge, so that there is better communication, stronger communication, and more real communication, moving forward, rather than saying, “Don’t talk”.
EB Because the insurer can really add to that process. We’ve had members that have claimed, and they’ve said that the claims consultant that took them through the claim became the person they spoke to the most about it, you know? Even more than their doctor, because they were constantly in contact. They were supportive. So, I see it as a really important role that they play, because they do understand. Obviously, you know, there are times people make judgements, as you mentioned. But, broadly, they are supportive of that person. They understand that, even though we may, at some point, decline the claim because they don’t quite meet the definition – it’s not that they’re well. They are unwell, just not quite – they haven’t crossed over the line, I suppose.
SS I think there’s been an important thing where we’ve actually tried to introduce that simple point of contact in our claims teams, so that you can build a relationship and trust. So, rather than just ringing the 1800 number and thinking, “Who’s going to answer my call today?” and they have to look it up, they’re ringing – “How are you today, Emma? I spoke to you yesterday. How did that go? Did that work for you?” – is trying to bridge that gap, so that there is a level of trust.
CF Unfortunately, if I start working with someone, I have some standard warnings I give them. One component of that warning is, “Do not assume the insurance company is going to be competent, timely, empathetic,” pick a whole lot of other adjectives. They may be, but don’t assume it. If you assume it, you’ll act in a particular way, and you’ll potentially get caught out. If you don’t assume it, you’ll act differently. That’s my experience. So, as prudent protection for the claimant, I will keep them apart from the life company, until the assessor – in my workings with the assessor, if I think the assessor’s competent, empathetic, timely, respectful – all those other things – I’ll get the hell out of Dodge. I’ll get right out of the way. But, if they’re not, there’s no way on this Earth I’m going to let them have one-on-one contact with the client.
SS And, that’s where it’s a shame. It’s a real shame that people who are unwell or injured feel the need to go to someone like you, or a lawyer, rather than come to the insurance company directly, because we’re ready to help, right? And, we talk all the time about, “How do we get people back, to help?” That is what we – I don’t know whether it’s always been like that, but this is what we do here. I find it disappointing that people feel the need to give up part of what they would receive as a payout, which, often, for people, isn’t going to be a massive amount of money. But, they’re giving up a large proportion of that because, upfront, they don’t believe that the insurance company is going to work for them.
CF And, way too often, they’re right.
SS Yeah. And, that is a real shame, in the experience that – that they actually don’t come to us first. And, maybe that’s part of the marketing. You hear it on the radio, where people don’t understand the process, or maybe they think it’s too hard, or it’s going to be adverse. Or, maybe they know someone. Because, not a lot of people claim. In reality, a very small proportion of the community actually ever make a claim. But, those that have a bad experience have a very loud voice. And, that can create a perception for many. But, as Emma said, we have some amazing stories where we’ve helped people with incredible outcomes to achieve lives and outcomes for their health and wellness that, probably, they didn’t ever think was possible. But, we don’t talk enough about – 
CF But, that’s the price of entry. Doing it well is the price of entry. So, if you go to a funeral director and they say, “We had 50 funerals today and we got 49 of them right,” great. That’s the price of entry.
JC Do you think your clients understand that the trustee is there to advocate for them, as well? The superannuation trustee’s job is to advocate for their position.
CF My experience with trustees – how do I put this nicely?
JC Don’t bother. Just go all the way.
CF Rubber stamp. The problem is this – I had this discussion with someone a long time ago. Is it better to be, or be perceived to be? Because, the trustees are perceived to be. Whether they are, or they are not, I don’t know. It’s just perception. Internal dispute resolution – I wouldn’t feed it. I’ve never had something go to IDR (internal dispute resolution), where IDR has overturned the decision of the insurer. Never. Never. Nil. Nought. None. Never. So, if the trustee wants to be seen to be doing the job because they are doing the job, I think they’ve got to go about it differently.
JC I agree. I don’t think anybody would have any understanding of the job that we do to advocate for members. It’s absolutely underneath the table.
CF And, you should tell them. You should be selling what you’re doing.
JC To what end? What purpose does that serve?
CF So that you are not only doing, but you’re perceived to be doing it.
JC It would make it easier for the members to talk to us, if they’re uncomfortable talking to the insurer. That’s for sure.
CF At the moment, I don’t think it makes any difference. Again, I can’t remember the last time I had a trustee overturn a decision.
JC You should come and sit with us a few times.
SS I was going to say, you should come and sit with me.
CF I will sit with you if you sit with me.
EB In my experience, if I disagree with the insurer, that happens before we tell the member the decision. So, by definition, if we don’t agree, it continues to go on until we reach some point of agreement. And then, we tell the member. It’s not after the fact, you know?
JC Which can add to your problems of delay, because there can be some serious debate going on between trustee and insurer.
CF A delay is one thing. Informing the claimant why there is a delay, in such a way that they actually understand what’s going on – and then, having a timeframe that you can look up in a diary, and it’s actually – it’s not what you get, which is, “It’s been referred to senior management. It’s gone back into the business. We’ll get back to you in due course.” I mean, that tells them nothing, but that’s absolutely what you get, every time. No one gives a timeframe. No one. It’s all, “As soon as possible. When I get around to it.”
SS What does that do for people with mental health – 
CF It drives them crazy because it’s so disrespectful, you know? If you ask someone out on a date and you say, “Look, I’ll get back to you in due course.”
MT I’d like to bring the medico in on all this.
SS I was just going to say, John’s probably got a view on this.
MT John’s been very quiet.
JA Well, mental health is a spectrum. It’s not just one condition. And, it’s complex, in the sense that – it can sometimes present as an acute condition. At other times, it’s chronic. At other times, it has a higher risk because you get comorbidities. I guess, that just adds another level of complexity. So, by the time it comes to be a claim, if it’s purely on a mental health diagnosis, it relates to so many other things, like – is the diagnosis right? For example, what stage of the journey is this patient on? Have they just been diagnosed? Is it chronic? Is it acute? Is it secondary to some other problem? I think, from a medical perspective, it’s, kind of, a – and, the paper that you sent out highlights the fact that a real issue [exists], in terms of how patients get to that point of diagnosis, in the first place – have appropriate treatment, in the second – so, they actually don’t end up, at the end, with a problem. 
Another problem I see is that I actually never hear about a patient’s claim until I get a letter from an insurance company, asking for a report. I suspect that’s – the same requests – whether they’re seeing a psychologist, or a psychiatrist, or a specialist, as well. My only contribution is what I know about the case. And, I’m kind of dissociated from being an advocate, because I actually don’t know anything else about what’s happening with that case, in terms of the claim.
Sometimes, I’m asked to write updates every month. It just seems to be endless. From your perspective, I can see that it’s like an endless pit, in some cases, because – at the same time, unless these people are being helped, they never get better. So, the claim will just continue on. That’s from the other perspective, of someone who’s a new diagnosis, or recently diagnosed, who has every opportunity of being well, or being treated appropriately. It’s like, who’s role is it to assist them? Does the insurer have a role and responsibility to assist with that, or are they just going to wait until they get to the end point, and figure out some payout? But, I can understand – 
SS I think we do have a role, John. I think it’s a really important role. And, I think – Lena can speak to this more, but that’s why we established a mental health team, and that’s why we established an early intervention team, and why we try to help people get back to work, because it’s an incredibly difficult cycle. If you’re off work, particularly with living with someone with mental health, it impacts the person. It impacts the family. It impacts the employer. It impacts the community. So, an insurer, working with someone to try and return them to health and return them to work, isn’t just about the dollars, in terms of the payout. It’s actually about the community and the better, because, as you know, someone being needed – one of the hierarchies of needs, of Maslow, is actually being needed. And, for someone who’s not needed, and who is lonely and isolated – it would be incredibly debilitating. So, to actually get people back – I think we do have an obligation to try and help because we have resources to do that.
LK We do. And, I love the fact – in life insurance – rehab in life insurance is – it’s not compulsory. That’s really important to me. I’ve worked in systems where it is. And then, I’ve seen it used in a very negative way. Whereas, here, it’s being able to say to customers, “This is the sort of support we can offer. This is how we can assist. This is what that could look like. We know that trying to recover, particularly from complex conditions like mental health or chronic conditions, can be difficult and challenging, and there’s a lot of uncertainty. If you’d like some support around that, we’re here to be able to offer that to you.” And, it has no implication on their financial security, because I think that’s – if I’m hearing you correctly before, Col, as well – people are really unsure about whether their benefits are going to be taken from them.
So, when it comes from our perspective, around supporting people, they need to know – this support that we’re offering has no bearing on what’s happening if you’re entitled to claim. That should not be impacted in any way. We’re here to try to support you, if that’s what you want. And, I know there’s been talk out there of, potentially, making it compulsory, which I – I personally don’t like.
CF Some companies, it is.
LK Yes. And, look, I’ve worked in systems where that has been compulsory, like worker’s comp, and the – where – my perception is – where I saw it go is – rehab was sometimes used in a negative way, of determining whether a person is entitled to payments or not. That’s not what we’re there for. And, people working in that profession – that’s not what they want to do. They actually want to be able to support and assist a person. And, you’re quite right, Suzanne. It’s not about that person. It’s their partner, their children, their entire families.
And, in this role, you see that. I think one of the most powerful things I heard, early on, working in life insurance, was having a customer saying to me, “If I did not have this insurance, I would not be here today. I would have taken my own life.” Do you ever hear that, Col?
Maybe you see the other side.
CF I hear, “I’ve got to stop this claim, on the advice of my treating psychiatrist, because if I do not stop this claim, it’s going to end me.”
LK Well, see, I guess – I’m thankful I’ve heard the other side of that.
SS What does that mean?
CF Because – the psych had actually said to the claimant, “If you do not get away from that insurance company, you’ll probably end up suicidal.” True story. And, the retail insurers – some of them, rehab is compulsory. And, dare I suggest, as recently as yesterday, the wife of a claimant said to me – new claim, coming on board – the fact that they had to submit monthly forms sent the message to them that the insurance company could cease that payment at any time. So, there’s no security in it, at all. The process of monthly forms was sending a message of insecurity.
LK A message of insecurity – but, it also sends a message of trying to reinforce unwell behaviour. If what you’re saying is – 
CF Which do they need?
LK If we’re wanting to move to a scenario of helping people through recovery and getting on with their lives, getting them to complete these forms is almost saying, “Tell me about how sick you are. You need to prove you’re sick, in order to get a payment.”
CF Yeah. That’s why we give them daily activity diaries and say, “Here, record it."
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