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Assessing psychosomatic disorders

01 June 2011 Dennis Booysen, FMI

The diagnosis of psychosomatic disorders may not easily meet a definition of permanent disability. It is therefore essential that advisors ensure suitable benefits are offered to meet their client’s needs.

Psychosomatic, somatoform or stress-related diseases are defined as conditions caused or aggravated by a mental factor such as conflict or stress, pertaining to the mind-body relationship.

This disorder is far more complex than the definition would suggest. Causes for the illness are not straightforward to identify and could be confusing for the doctor and the patient.

Theoretical approach

Three theories have been particularly popular in explaining why certain people develop psychosomatic disorders and what forms the illnesses take:

1. Psychological stress affects bodily organs that are weakened by stress.
2. Specific types of illnesses are linked to particular types of stress.
3. Psychosomatic illness develops when physiological predispositions are combined with psychological stress.

People suffering from psychosomatic disorders have been helped by either treating their physical symptoms, the underlying psychological causes, or both.

Practical treatment

All factors are taken into consideration when dealing with psychological and social factors in relation to physical disease. Psychosomatic disorder sufferers generally feel that doctors don’t take them seriously, which means that a trust relationship with a supportive and understanding therapist plays a crucial role in recovery. Treatment, which may include psychotherapy, hypnosis, cognitive-behavioural therapy or medication, is time consuming and success depends on the individual rather than the disorder.

Underwriting assessment

Diagnosis of an existing disorder at the time of underwriting is vital for underwriters to set the correct acceptance terms.

According to Mark Olfson, a psychiatrist at Columbia University in New York, reviews of claims records, which are diagnoses actually given by healthcare professionals, suggest that only about 50% of patients who are prescribed antidepressants receive a psychiatric diagnosis.

The underwriting outcome is often misinterpreted as inconsistent due to many elements, which may change at any time during the medical treatment protocol period. However, underwriters’ assessments are based on factual, objective medical evidence. Hence, at underwriting stage, an exclusion and/or loading, or even refusal, may be the most obvious result, particularly for occupational income protection benefits. This may be viewed unfavourably by the client, which results in client relation management challenges.

Claims assessment

The claims assessment process is influenced by the requirement that the claimant follows medical advice from a legally qualified and registered medical practitioner. This requires ongoing consultations and treatment adjustments.

Experience has shown that after maximum therapy, an individual will generally recover sufficiently to return to work. However, two further fundamentals influence the claim payment outcome.

Non-compliance to medical advice may be interpreted as undue influence to extend time booked off work. People with genuine medical conditions can qualify for the diagnosis if the level of functional impairment reported is more than would be expected based on medical findings. If the patient is feigning symptoms, a diagnosis of fictitious disorder or malingering would be considered.

The cause of the psychological condition may become an important factor. Is a claimant who suffers from burnout due to excessive working hours entitled to a claim payout, or is the accepted practice to take annual leave? Poor work performance creates conflict and exacerbates the condition, which may lead to malingering.

Holistic approach

Choose an insurer committed to meeting the obligations of claims payments and that supports the medical process until all avenues are exhausted. The frail situation of the claimant and the important trust relationship with the therapist should be respected, and the insurer should rather work closely with the medical practitioner to reach an agreeable solution.

Quick Polls

QUESTION

How to give affordable and appropriate financial advice to the low income market segment. There is little room on a R50 pm policy for advisers to be remunerated for the time it would it would take to educate & fulfil admin function. What is the solution?

ANSWER

[a] Eliminate non-advice sales / telesales
[b] Implement industry standards for non-advice information
[c] Introduce an insurer-funded pro-bono advice network to low income earners
[d] Reinforce the Policyholder Protection Rules
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