Forensic Consultation in Disability Insurance Matters
Piechowski, Lisa D., Journal of Psychiatry & Law
Consultation in disability insurance matters is an emerging area of forensic practice, but little has been written to inform work in this area. This article will first distinguish between evaluative and consultative roles, and then suggest a framework for practice in this area based on the principles of forensic mental health assessment developed by Heilbrun (2001). Adherence to such a framework can assist the consult in ensuring practice conforms to ethical and professional standards emphasizing objectivity, accuracy, and impartiality, while at the same time acknowledging the unique demands of the consultative role.
As the American population ages, the number of claims for disability benefits is increasing as well (Social security Administration, 2006). When these disability claims are based on diagnoses associated with mental health conditions, substance abuse, and/or cognitive impairments, the forensic psychologist or psychiatrist may be asked to serve in a consultative or evaluative role to assist in the adjudication of claims. Although there are broad variations in the nature of the claims and the kinds of assessment or consultation that might be required to assist fact finders, there are some fundamental concepts that govern the forensic psychologist's work in this arena. General forensic principles may provide a skeletal frame for the work, in the ways to be described here. Situational demands unique to disability evaluation and consultation will also be examined.
Disability benefits may be sought from a number of different sources, depending on the circumstances of the claimant. These sources include private disability insurance policies, public and private sector employee benefits, federal entitlement programs (Social security Disability), and worker's compensation. Each of these sources of benefits is subject to different federal, state, and local laws. For example, Social security Disability and private sector employee benefits are regulated by federal law (Social Security Act and Employment Retirement Income security Act of 1974 [ERISA]). Private disability policies are usually governed by the laws of state in which the policy holder resides. State and local government employee benefits are exempt from ERISA regulation and are defined by state statutes, local ordinances, and (when applicable) collective bargaining agreements. Worker's compensation is statutorily defined in each state.
"Disability", used in this context, is a legal, rather than psychological or medical, term. It is defined by the terms of the policy, contract, or entitlement program under which the claimant has applied for benefits. There are, however, some common elements among disability claims. Disability refers to functional capacity, not diagnosis. To be eligible for benefits the claimant must meet the specific threshold criteria for disability established by the policy or program under which benefits are sought. Regardless of the source, most definitions of disability include two prongs: (1) The claimant must have sustained an injury or illness that, (2) Renders him or her unable to perform the substantial and material duties of his or her occupation (or in some cases, to be able to perform any work at all).
Consultation in matters of disability
Although most readers are familiar with the use of mental health practitioners to conduct Independent Medical Examinations (IME) when psychological or psychiatric issues are at question, there may be less familiarity with the participation of forensic psychologists and psychiatrists as consultants on matters of disability. Known as "in house consultants" or "file review consultants," these practitioners are often retained by private insurance companies to assist with the adjudication of claims. As noted by Hadjistavropoulos & Bieling (2001), medical experts and psychologists may examine claimant files and provide opinions in areas about which insurance adjudicators have limited knowledge. …