1) The pain doesn’t match the pathology – is the claimant malingering?

At claims stage, we seek to understand the medical condition and the impact it has on the claimant. Part of this is to review the investigation results in the hope that they will corroborate the claimant’s account of their pain. Often this does not happen and may cause the adjudicator to become concerned that the claimant is malingering or trying to exaggerate their symptoms. However, every person experiences pain differently, and just because it may seem out of the ordinary for an adjudicator, this doesn’t mean the claimant isn’t experiencing it. In these scenarios, it is best to ask the claimant to articulate their pain and to keep a pain diary where they can track and monitor their symptoms, severity, and any improvement. This should be corroborated with medical and functional information from their treating specialist and a pain practitioner.

2) The claimant is not being actively treated for their pain, so how bad is it?

Often the thought is that if the claimant is not being actively treated for their pain, the medical practitioners can’t regard it as that significant – so why the claim? Again, we need to seek to understand the entire picture, including what treatment has been offered or attempted, what other options are available, and the cost. Referring the claimant to a practitioner who specializes in pain would greatly assist with insights and recommendations.

3) The claimant indicates that their pain is always of the highest severity – could this be true?

Do claimants really experience pain at 10/10 severity, all of the time? There may be instances where claimants feel that they need to impress upon the insurer how incapacitating their pain is, in order to get their claim paid. There may be different reasons for this, but one factor to consider is how they explain their fluctuating pain levels, when every day may be different. Again, keeping a pain diary may assist with a better view of the frequency of pain, over a longer period, as well as their functional abilities and limitations.

4) The claimant won’t attempt any rehab or work tasks, for fear of pain. Are they adhering to the rules of the contract?

In some instances, the rehabilitation providers may recommend a gradual return to activity, but the claimant may be reluctant to do this. This may be viewed as them being obstructive or uncooperative, but it may stem from their actual fear of the pain.  One of the best ways to handle this is through communication. Ask the practitioner to speak to the claimant directly and explain that any return to activity will be done with guidance and support. Constant reassurance and support will be required.  The claims adjudicator should also obtain regular feedback from the rehabilitation provider.

Claim checklist

• Do you have a thorough understanding of the medical condition?
• Has pain been reported? (What extent, severity, location?)
• Do you have functional information?
• Has the claimant been referred to a pain management practitioner/expert?
• Do you have a plan in place for managing the claim?
• Have you communicated with the claimant and any other role player(s)?

While pain is complex to both understand and manage, having the right approach and the right people to assist at claims stage will make a significant difference to the outcome.