File review consultation in the adjudication of mental health and chronic pain disability claims.

Abstract

The role of the psychological file review consultant in assisting disability insurance carriers to adjudicate chronic pain and mental health claims is discussed. The authors advocate an empirical basis for this practice and outline the relevant professional issues and procedural steps to be taken in this consulting role. They examine the role of the consultant in evaluating the quality of assessment, whether empirically evaluated treatments have been applied, and what factors can be used in estimating return to work dates. Specific problems that a file review consultant might encounter and suggested solutions are described as are potential biases and ethical dilemmas that may occur when psychologists take on this emerging consulting role.Thomas Hadjistavropoulos received his PhD in clinical psychology in 1991 from the University of Saskatchewan, Canada. Currently, he is professor of psychology and director of clinical training at the University ofRegina.Peter Bieling received his PhD in clinical psychology in 1997 from the University of British Columbia, Canada. Currently, he is an assistant professor in the Department of Psychiatry and Behavioral Neurosciences at McMaster University and is a psychologist at St. Joseph's Hospital in Hamilton, Ontario.

Disability assessments: Effects of response mode and experience

“…Other cases, however, are more complex, particularly when subjective interpretations are involved such as dealing with pain [2]. As there are no clear guidelines as to how such judgements need to be made, it is expected that variability across doctors making judgements on the basis of the same information will be high [3].…”

Handbook of Complex Occupational Disability Claims

“…These concerns have also been variously expressed in relation to specific disorders with extensive psychosocial features, such as Chronic Fatigue Syndrome (Afari & Buchwald, 2003;Coetzer, Lockyer, Schorn, & Boshoff, 2000Deale, Chalder, & Wessely, 1998;Jason, Richman, Friedberg, Wagner, Taylor, & Jordan 1997;Johnson, 1998;Wessely, 1997), Fibromyalgia (Coetzer et al, 2000(Coetzer et al, , 2001Gervais, Russell, Green, & Allen, 2001;Katon, Sullivan, & Walker, 2001;Winfield, 1997Winfield, , 2000, and chronic pain more generally Hart, Wade, & Martelli, 2003;MacFarlane, Stroud, Thorn, Jensen, & Boothby, 2000). In addition, for a more general discussion of psychosocial factors in disability, see ), Hadjistavropoulos & Bieling (2001, Khan, Khan, Harelezak, Tu, & Kroenke (2003), and William & Martin (2002).…”

“…Finally, the disparity between the claimant's functional capacity and the demands of his or her job must be compared to the specific contractual requirements, which vary depending on the type of compensation system (government, private disability, workers' compensation, etc. ), as well as the specific contractual definitions to be applied (Barron, 2001;Hadjistavropoulos & Bieling, 2001;Mitchell, 2000). Specifically, even once it is established that a medical impairment exists, the question of disability is whether the claim is compensable, and this is a contractual rather than a clinical issue.…”

“…; but if the job is sedentary and never requires the activity, then the impairment may not be a disability as determined by the relevant contract. Even an impairment that precludes some, but not all of the individual's occupational duties, might not meet the definition of disability as set forth in a particular contract (Barron, 2001;Hadjistavropoulos & Bieling, 2001;Mitchell, 2000).…”

“…This assists the adjudicator and medical or psychological consultants in making fair and appropriate determinations as well as allowing for assessment of any claims which appear to be over-stated or inappropriate and outside of the parameters of the contractual language. Careful analysis of adequate information is needed to make a thoughtful, thorough, and fair determination (Hadjistavropoulos & Bieling, 2001).…”