When an insured person registers with the IV, he or she must, among other things, name the doctors with whom he or she is receiving treatment. These are legally obligated to provide information to the IV. Often, the information provided by the treating physicians is more disease-oriented. However, the IV also needs information on resources that are still available in order to be able to fulfill its integration mandate. Accordingly, the doctor must also assess the ability to work, because it is not the medical diagnosis that gives rise to the claim, but the specific loss of benefits suffered by the insured person. The IV often uses expert opinions to clarify the medical facts and the resulting limitation of benefits.
They have all been annoyed by the IV. There are a lot of forms to fill out, after all, is assessed, and the decision is also not understood. The procedure is felt to be lengthy and the attending physician does not know what is going on. What does the IV do and what does it need?
IV registration and examination of the integration potential
With the IV registration, the insured person names doctors with whom he is or has been receiving treatment. These are legally obligated to provide information (Art. 6a IVG). The IV office obtains information and form reports from them – often in consultation with the Regional Medical Service (RAD). If these documents contain further indications of treatment by specialists or in clinics, the IV office can also request information from these sources. According to their treatment mandate, the information provided by the treating physicians tends to be disease-oriented and thus often deficit-oriented. In addition to information on health restrictions, the IV also needs information on the available resources in order to be able to fulfill its integration mandate.
First, RAD often reviews where physician or hospital reports reveal findings of permanent health problems and resulting consequences for job performance. Further inquiries or follow-up telephone calls by RAD to the treating physicians complete the picture.
If the insured person is motivated and confident, the cooperation of the IV staff in the integration department (and the RAD) with the insured person and the treating physicians is uncomplicated and good solutions can be found. If the insured person is in doubt as to whether he or she is healthy enough for reintegration, difficulties arise in the reintegration efforts. Insured persons are sometimes convinced that they are unable to work, even though many functional abilities are objectively preserved and there are no medically verifiable medical conditions that would justify total incapacity for any activity.
The assessment of the ability to work (AF)
For IV benefits, a (long-term) restriction of occupational capacity must be shown for health reasons. For pension benefits, it must usually be possible to prove this restriction to other professional activities. This item is asked in the doctor’s report under “Ability to work in adapted activity”.
This does not involve concrete proposals for alternative activities. The decisive factor is whether the insured person is able to perform other activities according to medical assessment. Can the insured person be present at an ideal workplace all day? Does he or she perform at a reduced level (estimated by how much), e.g., due to slowing down or rapid fatigability, and are there any other restrictions (e.g., not on ladders, not outdoors, no/low customer contact, etc.)? The more clearly these limitations and resources are formulated and derived from the symptoms of the present health disorder, the better the entitlement to IV benefits (both integration measures and pension) can be justified.
It is not the diagnosis that gives rise to the claim, but the specific loss of benefits. But the diagnosis is usually required for plausibility and also for prognosis assessment.
If the treating physician’s assessment of AF differs from that of his or her patient, he or she may also limit his or her testimony to a description of the symptoms and treatment and recommend independent clarification.
Different assessments of performance
Physicians assess medical issues differently. Discrepancies between treating physicians and physicians with more intensive training in insurance medicine (RAD, evaluators) are particularly common in the assessment of work capacity. This is due, on the one hand, to the different approaches (empathic long-standing relationship of trust vs. sober weighing of objectifiable limitations), but also to the different routines in the application of assessment criteria.
Treating physicians (primary care physicians and specialists/hospitals) also assess cases differently. In the case of all relevant deviations, the IV is obliged to carry out further clarifications until it has been sufficiently and justifiably clarified which assessment is most convincing.
The courts evaluate all medical assessments and reports very carefully as part of the free assessment of evidence. If evaluators/RAD determine different abilities than the treating physician, they must give good reasons. As a result, when there is a discrepancy in the file regarding the assessment of functional limitations/work abilities, an expert opinion is often ordered to avoid having the case remanded by the court for further clarification.
Expert opinion
Expert opinions to clarify the medical facts and the resulting limitation of benefits or the resources still available are frequently used in the IV procedure.
Since 2012, the polydisciplinary expert opinions (formerly MEDAS expert opinions) have been randomly distributed via an Internet-based platform. The Federal Social Insurance Office is responsible for the contracts with the polydisciplinary assessment bodies and for quality assurance.
In 2012, guidelines for psychiatric assessments in IV proceedings were developed under the leadership of the SGGP by a broad-based working group (to be found at www.psychiatrie.ch, “Recommendations”), which the Federal Social Insurance Office has also declared binding for the IV offices.
Particular importance is attached here, among other things, to taking a complete and detailed medical history: Not only disease-related data, but also detailed information on social and professional development and previous history must be requested. For example, information on the circumstances surrounding frequent job changes may provide clues to relevant disturbances in interactional behavior, e.g., in the context of a personality disorder. Structured interrogation of, for example, careers in the military or volunteer positions can also provide valuable information about past health problems or even resources.
Common weaknesses in expert reports
Anamnesis too medical: An often encountered weakness of expert opinions is that the anamnesis and the subsequent summary and assessment concentrate too much on medical diagnostics and make too little reference to the concrete symptoms and the level of function and its possibly also uninsured reasons. Not every subjective incapacity is illness-related and thus insured with the IV.
Appraiser feels sorry: There are cases that create in the appraiser the feeling that justice must now be done to this person by giving him a pension as compensation for all his also personal and health difficulties. This can lead to existing health problems being assessed as more serious than they actually are. Although this is often understandable, it is not permissible. Only clearly identifiable, diagnostically classifiable health impairments with directly derivable effects on occupational performance can be a medical prerequisite for claims to IV benefits.
Reviewers focus too much on the brief impression: Some reviewers base their assessment very strongly on the current findings and take little account of the development of the disease and the development of functional limitations. In particular, if the examination is performed only once, there is a risk here of not sufficiently appreciating important aspects of the disease and limitations.
Looking ahead: The question of prognosis and remaining treatment options often leads reviewers to estimate how performance would improve after a particular treatment. Such prognoses must be evidence-based and also take serious account of previous treatments. When in doubt, it is always correct to determine the current AF and outline treatment options.
Lack of knowledge of terminology: The occasionally well-intentioned recommendation that the insured person should first test or build up his or her resources within the estimated framework could be interpreted under IV law as meaning that there is no relevant AF on the free labor market. This means entitlement to a full pension.
Consistency check: Often, the assessment of performance is essentially based on the information provided by the insured. Unfortunately, consistency tests to determine whether the limitations complained of are actually plausible and compatible with everyday realities (driving, independent living, family) are rather rare. If inconsistencies are noticed (e.g., when investigating in different postures or in case of incompatible data in the dossier), they are sometimes mentioned, but usually not explicitly evaluated.
If cooperation is significantly reduced, the level of function cannot be ascertained with certainty. Then the insured person must be informed that without his cooperation the assessment is not possible. If necessary, the assessment must be terminated in such situations (and the IV office informed), or the uncertainties must be named in the assessment report.
Conclusion
The IV clarification procedure is complex and is becoming more and more demanding from a legal point of view. Contact the IV office or RAD (also by telephone) if you are unclear or have questions, preferably with a declaration of consent from the insured person. In this way, you can provide your patients with optimal support and deliver the information they need in a targeted manner.
Monika Hermelink, M.D., MHA
InFo Neurology & Psychiatry 2013; 11(6): 36-38.
