Proving BP Disorder to My Insurance Co.
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Q:  Proving Bipolar Disorder to My Insurance Co.


I have been diagnosed with depression, bipolar, ADHD, and obsessive thinking.  I have been on disability with MetLife through my previous employer.who terminated my employment after 9 months of disability ..I started out with non-hodgkins's lymphoma and the chemo triggered ongoing manic and depressive episodes. I stopped the chemo and began seeing my psychistrist every four weeks.since Sept. 2000..He has had me on Remeron, Prozac, Xanax and Ambien for several months...I tried depakote but have a blood disorder and could not continue...I had been extremely depressed...when I received the letter that MetLife was cutting me off effective Oct. 31, 2002  I went into a manic episode - I am now on Prozac, Lithium, and Trazodone.  MetLife is stating that I only have depression and claim that I am not getting appropriate treatment.....they only pay 2 years of disability for mental/nervous disorders.....however, they must pay until 2027 if I have bipolar.  Well I do and now they want me to prove it - HOW do I prove this and appeal their decision????  Any ideas?

Thanks you..
 

Dear Ms. E' -- 
I hope this is simpler than it looks.  The simple thing would be to submit your doctor's paperwork (e.g. progress notes or billing records) that should somewhere indicate the working diagnosis.  Hopefully that working diagnosis is bipolar disorder now that you've had a manic episode, as long as that was clear enough.  Thus, there should be a "paper trail" consistent with bipolar disorder. 

But, I presume it hasn't been that simple.  Something like:  the first mood diagnosis was depression, that's when you got on the Prozac, and so the insurance people are saying this your mood problem is depression and they don't pay for that.  (It's an interesting distinction, don't you think: we pay for one mood disorder but not for the other...?).  So, you'd have to make the case that the earlier presentation of depression was part of the bipolar disorder.  

One way to do that would be to explain to them (and in this case you're probably going to have to get your psychiatrist to explain to them, which may be another job in itself) that previous depressive episodes in someone who goes on to have manic episodes later would generally be regarded as part of the bipolar disorder that just hadn't "declared itself" as bipolar at that point.  For example, you could show them this mood chart of a young man who had two episodes of depression before his first mania (depressions down, manias up, hospitalizations red): 

This graph is typical of a common course of bipolar I disorder.  For example, it has been used to show why people worry so much about bipolar disorder being "misdiagnosed":  the disorder doesn't show what it "really is" until later, sometimes years later, so how is one to know when the first depressive episode appears if it's "bipolar depression"?  This is a huge issue in psychiatry, i.e. how we can help primary care doctors and others be more alert to the possibility that what looks like depression might be something more complicated, and something that could get worse if they just give an antidepressant.  For some literature references on that topic, you could look at the "antidepressant controversy" to show that this topic gets a lot of attention in psychiatry (it's not directly on this topic but several of the references could be useful).  

So you could, I suppose, if it came to this, tell the insurance company you're going to ask a series of mood experts (and you're going to get a lawyer to help assemble them and their answers, if necessary) the following question:  
"Doctor, if you saw a patient with the mood course shown in the graph above, would you regard the earliest depressive episodes, in retrospect (i.e. not at the time, but as you look back now), as episodes of major depression, or as part of the bipolar disorder that later declared itself?"  I would be stunned if more than one in ten would answer other than "bipolar".  If any did, it would be a semantic issue, not a diagnostic one, as you surely have it now.  Unfortunately, if I'm guessing about the insurance company's stance correctly, they are going to try to refuse your payments on the basis of such a semantic issue.   

Of course you'd want to make it clear to the insurance company that your lawyer's fees would be something the lawyer would be seeking on your behalf if it came to such a maneuver, perhaps or perhaps not in addition to some other recompense (don't listen to me on this part, though, you'd really have to ask a lawyer if that's realist, it's just me venting my frustration with insurance companies...).   Good luck with that.  Write back to us at Bipolar World and tell us how this turns out.  It could be useful to others. 

Dr. Phelps


Published December, 2002 

 

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