Workers' Compensation and Independent Psychological Evaluations

 

Mental Disability Claims

Mental health disability claims occur when an employee says s/he cannot perform job functions due to the presence of a mental disorder, such as depression, anxiety, or post traumatic stress disorder.  The mental disability can co-occur with a physical disability. 

With few exceptions, North Carolina requires employers with more than three employees to carry workers' compensation insurance.  Typically, employers offer benefit packages that are managed by a third party administrator or insurance company.   It is the responsibility of the third party administrator to adjudicate disability claims pursuant to state and federal rules and based on a weighing of evidence regarding the claim. 

Purpose of an Independent Psychological Examination (IPE)

The purpose of an IPE is to determine

    (1)  the presence of any mental health diagnoses, including possible etiologies;

    (2)  the functional capacity (ability to perform work duties) of the claimant;

    (3)  the extent to which the mental health diagnoses identified are related to any functional impairments; and

    (4)  any treatment or rehabilitation needs of the claimant, including estimated length of treatment.

While the IPE evaluator may determine the presence of mental health conditions, the employer, insurance company,or other third party administrator has the responsibility for determining whether or not the claimant meets the definitions of disability. 

When Is an IPE Needed?

A range of questions may prompt an IPE, including :

    1.  Routine review of the case.

    2.  When, despite treatment, the employee has not shown expected improvements.

    3.  When there is a change in status (length of treatment).

   4.  The emergence of new evidence to suggest inconsistencies among or a change in functional capacities.

The Evaluation Process

Evaluators of mental health claims interview the claimant and any other relevant parties; review collateral documentation; and conduct psychological testing, as necessary, in order to assist the employer or third party administrators make a determination of disability and scope of assistance offered.  Evaluations should be conducted in an objective and unbiased manner.  Reports should include a description of the evaluation process and procedures; behavioral observations of the claimant; any limitations of the interview or test data; and all test results, findings and opinions regarding the functional capacities and impairments of the claimant.  If requested, evaluators may also offer opinions regarding

Note regarding Informed Consent/Confidentiality Limits:  Evaluators explain the nature and purpose of the evaluation to the claimant, including that the evaluation is being conducted on behalf of the insurance company/third party administrator/employer.  The claimant should understand that there is no therapeutic relationship being established; that no treatment will be provided; nd that an evaluation report will be prepared and shared with the referring party.  In addition, the claimant should understand that the results of the evaluation may be used to determine the claimants eligibility for disability benefits.  The claimant has the right to refuse the evaluation. 

 

Relevant Laws, Standards of Practice, and Statutes

Key Terms and North Carolina Standards

The vast majority of employers with more than three employees must provide workers' compensation insurance.  If disabled, full medical benefits are provided to the employee.  The employer selects the physician.   

Temporary Total Disability (TTD) and Permanent Total Disability (PTD): payments are based on a percentage of the wage and subject to weekly min and max amounts; payments continue for the duration of the disability.

Permanent Partial Disability (PPD): payments are made based on a percentage of the wage, subject to weekly min and max amounts; payments may continue for up to 300 weeks. 

Landmark Cases:

Burlington Industries, Inc. v. Ellerth, Pub. L. No. 97- 569(1998).

Ellison v. Brady, 924 F.2d 872 (9th Cir., 1991)

Harris v. Forklift Systems, 510 U.S. 17 (1993).

Meritor Savings Bank v. Vinson, 477U.S.57 (1986).

Oncale v. Sundowner Offshore Services, Inc., 523 U.S.75 (1998).

Olmstead v. L.C. ex rel Zimring, 527 U.S. 581 (1999).

References for Evaluators:

Americans With Disabilities Act

Foote, W.E. (2003).  Forensic evaluation in Americans with Disabilities Act Cases.  In A.M. Goldstein (Ed.)., Forensic psychology (pp. 279-300).  New York: Wiley.

Melton, G.B., Petrila, J., Poythress, & Slobogin, C. (1997).  Chapter 12: Compensating mental injuries: Workers' compensation and torts, and Chapter 17: Education and habiliation, Psychological evaluations for the courts: A handbook for mental health professional and lawyers.  New York: Guilford.