Mental health claims that initially appear straightforward do not always follow the expected course. Such cases often have a clear situational trigger for developing a mental health condition – such as a life event, a workplace stressor, or a personal loss – and it is expected that, with time away from work and appropriate psychological and pharmacological treatment, the person will recover and return to their job. In reality, however, things do not necessarily unfold that way.
Despite time passing and treatment being in place, there is sometimes little to no improvement in function. The person’s situation does not change, their treatment plan remains static, and their recovery stalls. The claim extends well beyond initial expectations, and the path forward becomes increasingly unclear. For claims adjudicators, this can be difficult to manage. Not only are they trying to responsibly manage the claim on behalf of the insurer, but also they are striving to effectively support the customer.
In these circumstances, the complication of secondary gain can become especially relevant and challenging.
At its core, secondary gain refers to the external benefits a person may receive from remaining unwell. These can be financial, emotional, relational, or psychological, and they are often entirely subconscious.
It can be tempting to interpret secondary gain as deliberate manipulation, particularly in a complex claim scenario involving significant financial implications. But in most cases, that assumption is both inaccurate and counterproductive. Secondary gain is not synonymous with malingering. It is not about faking symptoms or manipulating the system. More often, it reflects a complex interplay of psychological needs, environmental reinforcements, and deeply human fears.
Claims professionals should think differently about this by resisting the urge to label; instead, leaning into curiosity:
One of the most subtle and powerful forms of secondary gain is psychological and emotional reinforcement. For some individuals, their illness becomes a source of control in a life where they previously may have felt powerless. The sick role allows them to influence others’ behavior, gain accommodation for their needs, and avoid situations that feel overwhelming or unsafe.
This is not manipulation; it is psychological survival.
Understanding this dynamic does not mean excusing stagnation. It means approaching it with empathy and strategy. It means asking, “What does recovery threaten to take away?” and “How can we help this person feel safe enough to move forward?”
Claims adjudicators are not (usually) clinicians, nor are they responsible for prescribing treatment. Their role is to assess claims fairly, manage them responsibly, and ensure that decisions are grounded in accurate, complete information, with a strong management plan. Within that remit, claims adjudicators still play a meaningful role in shaping the customer’s experience and supporting their recovery, especially when secondary gain is suspected.
The initial conversation with a customer is more than a procedural step; it is a strategic opportunity. It sets the tone, builds trust, and helps clarify expectations. When conducted with empathy and curiosity, it can uncover subtle barriers to recovery and create space for collaborative problem solving.
When signs of secondary gain emerge – such as ambivalence about treatment, avoidance of activity, or inconsistent presentation – the claims adjudicator’s role is not to confront; rather, it is to explore, seek clarification, consult with treating providers, and ensure that the claim is managed with a full understanding of the customer’s situation. Motivational interviewing techniques can help claims adjudicators explore ambivalence respectfully. Questions that invite reflection like “What do you think would change if things started to improve?” or “What’s been holding you back from trying [activity]?” can prompt reflection and open the door to more productive conversations.
In some cases, claims adjudicators may also need to consider the influence of family dynamics. When well-meaning relatives assume responsibilities or discourage activity, they may be unintentionally reinforcing dependency and hindering recovery. Including them in rehabilitation planning, when appropriate and guided by the treating provider, can help shift the focus from protection to empowerment.
Long-term mental health claims that appear static on the surface can present some of the greatest opportunities, or challenges, for intervention. Consider the following two scenarios.
In one scenario, a claim has remained unchanged for several years. Monthly reports show no variation in symptoms, treatment has not evolved, and there is no specialist input. The clinical presentation is repetitive, and the recovery trajectory has stalled. In response, the claims adjudicator initiates a comprehensive reassessment. Rather than accepting the status quo, they review the full history of the claim, identify gaps in care, and collaborate with the treating medical provider to explore treatment optimization. This includes referrals for specialist input, adjustments to medication, and the introduction of structured psychological support. A graduated activity program is also implemented to rebuild functional capacity and confidence.
Over time, the customer begins to engage more actively. Improvements in sleep, mood, and daily functioning emerge, and they eventually return to work on a part-time basis. The shift is not just clinical, it is psychological. The customer begins to see themselves not as permanently disabled, but as someone recovering from a complex set of previously unaddressed challenges.
In a contrasting scenario, a similar claim is approached with minimal engagement. The claims adjudicator attempts reactivation through respectful outreach, motivational interviewing, and voluntary specialist input. However, the customer remains disengaged, resistant to change, and firmly entrenched in the sick role. Despite multiple efforts, they decline further rehabilitation support.
Faced with this reality, the claims adjudicator adopts a hybrid strategy: maintaining low-touch contact, documenting all efforts, and keeping the door open for future engagement. While no immediate progress is made, the groundwork is laid for potential reactivation should circumstances shift.
These two outcomes highlight a critical truth: the claims adjudicator’s approach can shape the trajectory of a claim. Proactive, collaborative engagement may unlock recovery in cases that appear stagnant, while respectful persistence can preserve trust and readiness in those not yet prepared to move forward. This scenario reflects the complexity of mental health recovery and the importance of meeting customers where they are.
Secondary gain represents one of the most complex barriers to recovery because it touches on the customer’s fundamental relationship with their illness. Addressing it requires a blend of clinical insight, psychological sensitivity, and strategic case management. It means recognizing that resistance may stem from fear, not defiance; that recovery can feel threatening, not just hopeful; and that progress often begins with a single, supported step.
For claims adjudicators, this means working closely with treating providers, developing return-to-work strategies that acknowledge the customer’s fears, and ensuring that recovery does not come at the cost of losing all support. It means maintaining empathy while still advocating for appropriate treatment and functional progression.
Ultimately, understanding secondary gain is not about labelling or confronting; it is about seeing the whole person, not just the claim. Doing so can help create space for recovery to begin, even in the most complex of cases.
Browse more Global Claims Views content, which discusses claims management issues with experts.
