Diagnoses of mental and nervous disorders are rising, work leaves related to these diagnoses are also increasing, and many of these disabilities involve a work-related issue, such as conflict with colleagues or a direct supervisor, work overload or performance issue. Case managers face important challenges when it comes to the initial decision or the adjudication of these files.
Certain diagnoses are more common when work-related issues are present, as are conditions, both physical and emotional, that cause subjective symptoms. Diagnoses frequently observed in cases involving work-related issues include (but are not limited to): major depression, adjustment disorder, burn-out, chronic fatigue syndrome, generalized anxiety disorder, stress, chronic pain, and fibromyalgia.
It is sometimes difficult for the case manager to identify the work-related issue. But the sooner the issue is identified, the sooner the case manager can actively work with the claimant and the employer to support a positive resolution of the claim. To help determine if there is a work-related issue, the case manager should look for certain signs, such as:
- Work-related information on the initial forms
- Inconsistencies between the medical information and the information given by the employee or the employer
- Quick improvement following the work leave
- Difficulty reaching the employee
- The employee refuses to receive treatment or rehabilitation support
- The employer takes special precautions when giving information about the file or in the reintegration process
When a claim is received, even before conducting the telephone interviews, the case manager’s first action should be to compare all the information: the initial forms, the medical information and the contractual provisions.
In every case, a good comprehensive telephone interview should be completed with the claimant and the employer to compare their versions with the medical information and identify the work-related issue at the onset of the claim.
The case manager should always keep in mind that the main task is to assess the employee’s functional limitations and capacities, and compare them with the work demands. Obtaining information about the employee’s capabilities with regard to activities of daily living (ADLs) is also important because if the alleged symptoms and functional limitations are inconsistent with the ADLs, the case manager should dig deeper to determine if the symptoms are work-related only.
If there are inconsistencies, the case manager should document the file as needed – for example, get a copy of the medical records, including test results and specialists’ reports. Obtaining all available medical information is necessary in order to discover and assess what was discussed during the employee’s visits with the doctor. If the employee talks about his or work situation at length but provides little or no information about symptoms he or she is experiencing, that is a red flag suggesting a possible work-related issue. Quick improvement of the symptoms following the initial visit is another red flag. The case manager should also gather specific information about the claimant’s professional situation (list of absences, details concerning the situation before the absence, etc.) as necessary.
Whether it is due to conflict with a supervisor or colleagues, performance issues or work overload, having a difficult work situation, can be stressful, so it is normal to experience negative symptoms. The employee may suffer from bouts of crying, anger issues or difficulty concentrating. But if these symptoms disappear quickly (in a few weeks) when the employee is absent from work, the case manager should then question if the employee is really disabled. In the case of a disability, the symptoms should be present in multiple spheres of the employee’s life, and not only at work.
Not so long ago, case managers were taught that, when analyzing the initial forms, if they had “a diagnosis, the presence of symptoms and a treatment,” disability could then be approved. In the last few years, the industry has started to move to an era where the focus is now on the employee’s functional limitations and capacities. This approach is even more valid in work-related-issue cases.
When all the information needed to assess the claim is in hand, the case manager now has to make a decision. It is often a good idea to have a claim discussion with internal resources to ensure that the right decision is taken.
If the claim is approved, the real challenge starts! If the case manager determined that there are functional limitations that are incompatible with the job demands, his or her goal will now be to help the employee through the return-to-work process. As the work itself often represents a significant barrier preventing the employee’s return to work, the case manager should use all the tools he or she has to support the employee and the employer in the return-to-health mechanism. It is also worth keeping in mind that the resolution of a file is not always a return to work at the same job, even if the claim is still in the “own occupation period.” If the employee decides to take a new position, the situation could turn into a long-term win-win for all parties involved.
Rehabilitation services often provide great support in these types of claims. Some examples of interventions include a home visit, a mediation meeting between the employee and the employer, job search support and ergonomic assessments. Creativity and innovation are the keys to effective assistance as each situation is unique and deserves its own solutions.
