Physical assessments, medical records, and reports for specialized testing play a major role in resolving a claim. This is especially true when litigation is involved. The impact of an injury at work or an accident on the road isn’t easy to put a dollar value on. However, this is what claims adjusters and legal professionals must do; patients' lives and recovery times are aided by well-supported cases where the resolution is both timely and fair. 

Unfortunately, a speedy resolution doesn’t always happen when the claim is related to mental health. While physical issues aren’t easy to put a dollar value on, psychological concerns are even more complex. Illness or issues that are invisible to observers, as in the case of mental health, make it difficult to document typical factors for a workers' compensation or disability claim: is the mental health concern work-related? Is this a pre-existing condition? Is the person still able to work? How will the patient be treated, and for how long? 

According to researchers at Deloitte, rising levels of mental health claims have left insurers and legal professionals to contend with new issues in workers’ comp. These more complex claims have more complex documentation needs – and accuracy plays a higher role. 

Why are psychological assessments and medical records so important for a claim? 

In criminal cases, psychological assessments are commonly used by defendants to prove that they were not mentally capable of understanding their crime. Psychological assessments are also used in court cases to test the fitness of a parent for custody rights. In the insurance context, psychological assessments are used to gauge the cause and severity of mental health challenges such as post traumatic stress after returning from a military zone, or witnessing an accident at work. 

Psychological assessments and medical records form the basis of mental health claims. Just as ultrasounds or CAT scans show the extent of a physical injury, it’s up to the mental health professional to determine a patient’s mental needs. In Canada, the insurance system uses the DSM-5 system. This means physicians need to provide support for each symptom they base the diagnosis on. For example, if the patient was diagnosed with post-traumatic stress disorder following an accident, the patient might describe symptoms like feeling numb or cut off, nightmares, or poor concentration at work in their assessment. The psychologist conducting the assessment would document these symptoms to support their diagnosis. 

Medical records are also a factor in gathering support for a claim. Does the patient have a diagnosis? When was this diagnosis made? Have they been receiving consistent treatment for the mental health issue? For how long? 

If the treatment – and the issue – started only after the accident occurred, the medical records provide a clear source of support to the lawyer for the claim. If the patient had other issues that may have been exacerbated by the accident or injury, the court may use a tool such as a psychological assessment to get a clearer picture of the patient at the time of the claim. Although these issues can be ‘invisible’ to a CT scan, the symptoms are visible in the patient’s behaviour at work and at home. Documenting these symptoms and their manifestations is therefore key to successfully resolving a case. 

Psychological assessments (and other medical records) can make or break a claim

A Canadian Supreme Court (SCC) case in 1992, Frenette v. Metropolitan Life Insurance is not only a precedent setting argument for the limits of confidentiality under the Charter of Rights and Freedoms, it also illustrates the power of access to medical documents for swift resolution of a claim.

In Frenette, Mr. Frenette issued a life insurance policy on his son and gave the insurer permission to access his son’s medical documents. His son then disappeared and was found deceased, with the cause of death ruled as drowning. However, since the insurer had access to medical records, they noted Frenette’s son had been in an emergency room for a possible drug overdose two days before his disappearance. Consequently, the insurer paid out the life insurance, minus the $10,000 rider for a death ruled accidental. Following the denial, Mr. Frenette tried to block the insurer from accessing hospital records containing his son’s mental health history. However, the Supreme Court held that the insurance company had permission and should be allowed to access these files – because they are so central to the case.

Insurers are still not allowed to go ‘fishing’ for a prior issue in medical documents, but Frenette taught legal and claims professionals that medical records are paramount. The Supreme Court held that access to mental health records, while sensitive, are “inextricably linked to the ability to prepare a full defense.”

The result? Documentation, assessment, and medical record-keeping should be provided to an insurer when requested. For lawyers, these same documents will provide the foundational argument for the case.

Easier access to medical records supports better outcomes for patients

While physical and mental health impairments can be time-consuming to resolve through the courts, having clear, accurate, and complete documentation has a major impact on the patient’s ultimate rehabilitation. Good records mean lawyers and insurers can come to an agreement faster – meaning the patient spends more time recuperating, and less time worrying about the results of their claim.