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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