Global Claims Views: Claims Management Principles in the Evaluation of Disability for Post-COVID-19 Fatigue Claims

Disability claims (lump sum and income benefits) for Chronic Fatigue Syndrome (CFS) are not uncommon.

The aim of this article is to remind adjudicators of the claims assessment and management principles that should be followed when dealing with these complex claims in the context of COVID-19 and specifically “Post-COVID-19 fatigue”. A holistic approach that identifies and understands the biopsychosocial factors that may influence a claim is recommended.

Diagnostic criteria for chronic fatigue syndrome (CFS)

The Institute of Medicine proposed the following diagnostic criteria in 2015.

Diagnosis requires that the following three symptoms are present:

1. A substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social, or personal activities; that persists for more than six months and is accompanied by fatigue, which is often profound; is of new or definite onset (not lifelong); is not the result of ongoing excessive exertion; and is not substantially alleviated by rest, and
2. Post-exertional malaise*, and
3. Unrefreshing sleep.*

At least one of the two following manifestations is also required:

1. Cognitive impairment*, or
2. Orthostatic intolerance. Additional symptoms may include pain, immune impairment, and infection.

* Frequency and severity of symptoms should be assessed. The diagnosis of ME/CFS should be questioned if patients do not have these symptoms at least half of the time with moderate, substantial, or severe intensity.

Treatment for CFS

Neither a cure nor a standard of care treatment exists for CFS. The focus of treatment is to address the symptoms associated with the condition, including sleep disorders, pain, depression and anxiety, as well as cognitive dysfunction such as memory and concentration difficulties.

Maintaining physical activity is important and may improve fatigue and other symptoms. Excessive activity and exercise, however, can exacerbate post-exertional malaise (PEM), i.e., worsening of symptoms following physical or mental exertion, typically 12 to 48 hours post-activity and that can last days or even weeks.

Considerations and important points

• PEM: Activity management, or pacing, is reaching a balance between activity and rest. The limits for each claimant are determined on an individual basis and the goal should be to remain within these to avoid PEM flare-ups. Activity and symptom diaries are useful in helping determine the limits for each individual. Vigorous exercises are not tolerated well.
• Rehabilitation specialists that are experienced in the management of CFS can help claimants make the necessary adjustments to their lifestyle and adapt the way in which activities are performed to preserve energy.
• Sleep: Good sleep habits are important and additional support through medication may be required to achieve a full night’s sleep.
• Pain: Deep muscle and joint pain, as well as pressure-like headaches and soreness of the skin are examples of the pain behavior that a claimant may experience. A combination of medication, prescribed by the attending medical practitioner, and supportive modalities such as acupuncture, toning exercises, gentle massage, and hydrotherapy may also be helpful.
• Depression and anxiety: During the initial phase of their condition, claimants may become depressed and anxious, or experience high stress levels. The attending medical practitioner may refer to a mental health specialist for the management of these co-morbid conditions. The prescription of medication should consider potential side-effects that may have an adverse effect on the CFS symptoms, and although they may be helpful in alleviating some symptoms, they are not a cure for CFS.
• Orthostatic Intolerance: A referral to a neurologist or cardiologist may be indicated; however, in the absence of heart or blood vessel disease, the attending medical practitioner may advise an increase in daily fluid and salt intake.
• Memory and concentration problems: Tools like organizers and calendars can assist with memory problems. Some clinicians have prescribed medication that is typically used in the management of attention deficit / hyperactivity disorder (ADHD); however, there is a risk of the claimant pushing themselves to do too much and then suffering a ‘crash’ as a result.
• Additional and supportive strategies that do not involve medication include professional counselling, a balanced diet, nutritional supplements if a deficiency has been identified, and massage therapy.

Chronic fatigue in the context of COVID-19

In Part 1 of this publication, several objective and clinical criteria have been mentioned that can help the claims adjudicator identify claims that are extending beyond the expected recovery period post-COVID-19 infection. It is expected that most individuals recover from the effects of COVID-19 within six weeks. The starting point is a confirmed diagnosis of COVID-19 followed by a protracted period of fatigue lasting more than six weeks post-onset; other adverse indicators may include:

• Admission to intensive care unit (ICU) for the medical management of COVID-19
• A confirmed diagnosis of acute respiratory distress syndrome (ARDS)
• Existing or a prior history of mental health conditions
• Impaired or reduced level of functioning at the time of diagnosis

Initial claims assessment

From the outset it is important to affirm RGA’s philosophy that a diagnosis in itself does not validate a claim admission for disability. The definition of the insured event, i.e., inability to work due to illness or disease, is the starting point against which CFS claims are to be adjudicated. The understanding of how the condition affects the insured’s ability to perform their occupational duties or other specified criteria stipulated by the policy terms and conditions remains central to the assessment and management of disability claims.

Consider the following recommendations:

• Through a process of tele-interviews, obtain a good understanding of the insured’s medical history as well as their functional and social circumstances. This initial discussion will help adjudicators identify additional areas of investigation to be performed and to be specific and targeted with requests for further claims evidence.
• Important details should be noted regarding medical history including the presentation and management of COVID-19 diagnosis, clinical evidence such as recent lung function test results, current medication, and other treatment regimens being followed.
• A paper review of existing medical evidence by a Chief Medical Officer (CMO), followed by an independent medical examination, can be useful to obtain a second opinion on the diagnosis of chronic fatigue. Where a claimant is being managed by a general practitioner only, a discussion should take place with the CMO to determine whether the lack of specialist intervention is appropriate and whether specialist input should be recommended as part of the claims management strategy.
• Functional enquiries should get a good understanding of the insured’s performance in various roles and activities of daily living prior to the diagnosis of COVID-19, and this can be contrasted to current levels of functioning and performance of usual roles. The approach to establishing a functional benchmark at the time of claim may vary. The initial assessment as part of a physical conditioning program may be preferred rather than a functional capacity evaluation (FCE). Claimants may respond better to the environment in which the baseline assessment is performed as part of the therapeutic treatment program.
• In some markets, an FCE may be utilized to objectively determine the claimant’s level of functioning with regards to daily activities, cognitive abilities such as concentration and memory, as well as physical components including endurance. When requesting an FCE the insurer should ideally recommend professionals that are experienced in dealing with fatigue patients. There may be self-limiting behavior from the claimant however when participating in an FCE due to fear that this evaluation may cause a flare-up in PEM.
• The insured’s social circumstances and support structures should be understood in the context of identifying barriers to recovery and return to pre-morbid functioning, including a return to work. Conversely, where support exists that will enable improvement, these should also be identified and incorporated in the claims management plan.

• The worldwide economic impact of the pandemic is devastating, with high job losses being reported in most affected countries. A solid understanding of the insured’s work environment and circumstances is required. The absence of a job or business to return to is an additional barrier to overcome when targeting an improvement in all spheres of life. The recently published article “Return-to-Work in the context of COVID-19” provides detailed guidance on how to address return to work goals in these challenging times.

A number of questionnaires and tools that may be useful for assessing CFS can be found in the clinician’s guide published by IOM.

Ongoing claims management for disability income claims

• The management of these complex claims should be handled by experienced adjudicators and, where available, a specialist case manager.
• Although the circumstances of each individual claim will dictate the most appropriate management plan, frequent and open communication remains the foundation for a successful outcome for both the insurer and claimant.
• A clear and detailed management strategy should be created for each claimant, and the goals of this strategy discussed with all the relevant stakeholders.
• Communicating early in the claims management process with the treating medical practitioners helps to establish rapport and a partnership with the insurer.
• Goals for incorporating work as part of the treatment plan should be discussed with the claimant, employer, and treating medical practitioner to ensure buy-in from all interested parties. Without the commitment from all these stakeholders, it is unlikely the insurer will achieve a successful and sustainable return to work / business.
• The expected duration for disability income claims should be recorded and monitored, and a frequent discussion with colleagues in valuations teams should take place to share claims data on the number and duration of claims being assessed and managed.
• The payment of partial benefits where some residual vocational capacity exists can be a good option for both the insurer and claimant.

Summary

This guide is a reminder of the many complexities that exist within CFS claims and is cautionary in that long-standing fatigue may be a feature of some individuals that were diagnosed with COVID-19. Although it may be too soon to see the full extent of this phenomenon, claims teams should be ready to deal with these claims if or when they arise. Specialist adjudicators with the necessary experience and skills should be identified to assess and manage post-COVID-19 fatigue claims and an overall strategy should be created to address how these complex claims will be identified, assessed, and managed.

A number of resources within the RGA Global Claims Manual exist that provide additional tools to help claims adjudicators perform telephone and functional interviews, as well as explain principles about the preferred biopsychosocial model to evaluate and manage CFS claims.