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Claims Considerations for Pain Disorders: Common challenges and potential solutions

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Pain-related conditions are complex to assess and manage. The reason for this is multifaceted, but it primarily stems from the fact that we cannot see or measure pain. 

Claimants with pain should not be considered difficult or high maintenance – they have pain and deserve compassion and respect. Understanding the physiology – to the extent that we can – and the context is critical to identify the right treatment for the right claimant at the right time. 

Learn more on the physiology of pain: 

In this article we discuss four common challenges at claims stage and potential solutions: 

1. The pain does not match the pathology. 

At claims stage we seek to understand the medical condition and its impact 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 concern that the claimant is malingering or exaggerating symptoms. Everyone experiences pain differently and even if the claims adjudicator finds it out of the ordinary, it does not mean the claimant is not experiencing it. 

In these scenarios it is best to ask the claimant to articulate the pain and keep a pain diary where symptoms, their severity, and any improvement can be tracked and monitored. The pain diary should be corroborated with medical and functional information from the claimant’s treating specialist and a pain practitioner. 

2. The claimant is not being actively treated for the pain. 

It is often assumed that if the claimant is not being actively treated for pain, medical practitioners do not regard it significant – so why the claim? Again, the entire picture should be evaluated, including any treatment offered or attempted, other options available, and the cost. Referring the claimant to a practitioner who specializes in pain can generate additional insights and recommendations. 

3. The claimant indicates that their pain is always of the highest severity. 

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

4. The claimant will not attempt any rehab or work tasks, for fear of pain. Are they adhering to the rules of the contract? 

In some instances, claimants can be reluctant when rehabilitation providers recommend a gradual return to activity. This may be viewed as obstructive or uncooperative, but it may in fact stem from fear of pain. Communication, as well as constant reassurance and support, are key: Ask the practitioner to explain directly to the claimant that any return to activity will be guided and supported. The claims adjudicator should also obtain regular feedback from the rehabilitation provider. 

The following checklist can be helpful for pain claim adjudicators: 

  • Do you have a thorough understanding of the medical condition? 

  • How 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’s multidimensional nature makes it complex to both understand and manage, taking the right approach and engaging the right people at claims stage will make a significant difference to the outcome. 

At RGA, we are eager to speak with clients about any support needed. Contact us to learn more about the resources, solutions, and services available.  

The Authors

  • Belinda Thorpe
    Head of Claims Africa and
    Middle East 
    RGA South Africa 
  • Linda Hiemstra
    Occupational Therapist


Pain-related conditions are complex to assess and manage. In this article, Belinda Thorpe, Head of Claims Africa and Middle East, RGA South Africa, and Linda Hiemstra, Occupational Therapist, Back2Work, discuss four common challenges at claims stage and potential solutions.