Disabling Disability Claims in Gastroenterology

653 D Jack Richman is the Executive Vice President and Medical Director of ASSESSMED. Dr Richman, after being in family practice from 1968 to 1977, specialized in occupational medicine, pain management and disability evaluation. He is Past President of the Canadian Society of Medical Evaluators. In addition, Dr Richman is a Diplomat of the American Academy of Pain Management, and a founding Member of the Canadian Pain Society and the International Association for the Study of Pain. PA: Can you give us some background information on the assessment of disability in Canadians? JR: While insurance companies may make it seem that we are covered for any and all illnesses and injuries from cradle to grave, that is not the case. The role of insurance traditionally is to provide benefits for income replacement in terminally ill cases, or during a transition period from an acute illness to functional improvement. Once management of the acute condition or the acute phase of a chronic condition has occurred, one no longer medically qualifies. Unfortunately, this is not what insurance companies convey when they sell their policies. We, and the patients, often take away the impression that we receive benefits until we are cured or symptom-free. However, the presence of symptoms or perceived functional difficulty does not mean our patients qualify for benefits. For example, after a colectomy, ulcerative colitis patients are cured and usually return to work. This is often not true of Crohn’s disease. Two different inflammatory bowel diseases, two different patterns and outcomes. To automatically qualify, a patient must have a bona fide and well-defined medical condition that is in an acute or progressive state. Symptoms alone do not qualify the patient for benefits. The American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th Edition (1), states that disability is due to a “medically determinable” impairment. This is defined as an impairment that has demonstrable anatomic, physiological or psychological abnormalities. Abnormalities that manifest themselves only as symptoms do not qualify. PA: So when does a patient qualify for disability? JR: In my opinion and experience what I see is either: