Encyclopedia of Psychology and Law

the claim to determine if the policyholder is entitled to

benefits. Mental health claims are particularly difficult

to adjudicate as they are based on subjective symptoms.

During the course of the claim investigation, psycholo-

gists and psychiatrists are often called on to perform

independent medical examinations (IMEs) to assist the

insurance company in assessing the objective basis of

the claim. If the claim is denied or terminated, the

claimant may request an appeal of the decision by the

company. If this decision is unfavorable to the claimant,

the claimant may initiate legal proceedings against the

company.

In the assessment of disability claims, the key issue

is functionality; specifically, has the claimant’s ability

to function in his or her occupation been impaired?

Thus, in the IME, three questions must be addressed:

(1) Does the claimant have a psychiatric condition?

(2) Are there functional impairments related to this

condition? (3) Do these functional impairments affect

work capacity?

It is important that the concepts of diagnosis,

symptoms, and functional capacity not be confused.

Diagnosis refers to the presence of a specific psychi-

atric condition (e.g., bipolar disorder, panic disorder

with agoraphobia). Symptoms refer to the subjective

experience of the condition (e.g., loss of interest, anxi-

ety). Functional capacity, however, refers to the ability

to perform specific tasks or activities—for example,

interacting appropriately with the public, remembering

pertinent information, adding a column of numbers.

It is the loss of functional capacity that is critical in

the evaluation of a disability claim. Thus, it is necessary

for the evaluator to draw logical connections between

diagnosis, symptoms, and functional impairment, for

example, establishing how depression—manifested by

symptoms such as insomnia, diminished concentration,

and feelings of fatigue—leads to a reduced capacity to

stay alert and focused over the course of an 8-hour

workday, compromising the claimant’s ability to do his

or her job.

Workers’ Compensation Claims

Workers’ compensation is essentially a no-fault sys-

tem of compensating employees for losses due to

accidental injury or illness sustained in the course

of employment. Whether the injury is due to the

employer’s negligence or the employee’s, the com-

pensation is the same. This reduces the need for pro-

tracted litigation, allowing employers to contain costs

and employees to obtain the needed benefits in a

timely manner. The benefits provided by workers’

compensation include both lost wages and medical

care to treat the injury or illness.

The laws governing workers’ compensation differ in

each state. In all states, employees are compensated for

physical injuries, such as a knee injury caused by lift-

ing a heavy piece of equipment. Employees in most

states are also compensated for physical injuries origi-

nating out of mental stimuli (e.g., ulcers attributed to

job stress) and mental injuries that accompany a physi-

cal injury (e.g., posttraumatic stress disorder following

the loss of an eye). In only a few states are employees

compensated for purely mental injuries, such as panic

attacks resulting from a stressful work environment.

Unlike disability, in workers’ compensation, the key

issue is causality. To be compensable, the claimant’s

injury or illness must be the result of his or her

employment. From the standpoint of assessment, this

requires both establishing the existence of an illness or

injury and ruling out non-work-related causes of the

employee’s difficulties. In the workers’ compensation

system, independent evaluations are referred to as

qualified medical examinations (QMEs). The ques-

tions the QME is typically asked to address include the

following:

1. Did work cause or contribute to the illness or injury?


2. Are there preexisting conditions contributing to the
   disability?


3. Is there a need for current or future medical care?


4. Is the condition stable and not likely to improve?


5. Is there permanent impairment?


6. Can the claimant return to his or her regular job?

Evaluation of Disability and

Workers’ Compensation Claims

Given the subjective nature of psychological condi-

tions, it is critical for the evaluator, when assessing dis-

ability or workers’ compensation claimants, to use a

variety of data sources in forming opinions. These

sources may include (a) a review of relevant medical,

psychological, educational, and occupational records;

(b) collateral information obtained directly from third

parties, such as treating providers, family members, or

coworkers; (c) information obtained from the claimant

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