In the pandemic’s aftermath, more insurance and health care professionals have been presented with an unusual and complicated set of novel claims involving cases of long COVID-19.
This diagnosis has introduced new challenges to the insurance world. As adjusters, it’s critical to understand the evolving COVID-19 landscape so that we can evaluate and treat long COVID claims responsibly and compassionately.
Although the domain is still so new, information on long-term outcomes is scant and resources are hard to source, the following lessons are based on our experience. As part of our series exploring what it takes to do the adjuster’s job successfully, let’s consider long COVID, its status as a disability, the latest trends, and key considerations for investigating these often-tricky claims.
Long COVID symptoms can be wide-ranging
Long COVID, also known as post-COVID Conditions (PCC), refers to the signs, symptoms and conditions that persist or develop after an initial COVID-19 infection. People also refer to it as post-COVID Conditions, long-haul COVID, post-acute COVID-19, long-term effects of COVID and chronic COVID.
No matter what it’s called, the condition features an array of symptoms including fatigue, respiratory issues, neurological and psychiatric symptoms, digestive problems and more. It can be a challenge to diagnose since its symptoms often overlap with other potential health conditions.
According to the CDC, long COVID typically becomes identifiable at least four weeks after the initial COVID-19 infection and usually starts within three months of contracting the virus. Symptoms last for at least two months and, from a claims perspective, cannot be attributed to another underlying condition.
It is considered a disability
Long COVID can indeed be considered a disability under a variety of federal acts, including the Americans with Disabilities Act (ADA), Section 504 of the Rehabilitation Act of 1973, and the Patient Protection and Affordable Care Act. It’s essential, however, to emphasize that not everyone with long COVID automatically qualifies as having a disability.
It’s important to assess each case individually to determine if long COVID substantially limits a major life activity such as working, walking, or concentrating. Major life activities encompass a broad spectrum, including physical and mental functions, as well as the operation of bodily systems or organs, and even mental health.
A thorough and meticulous investigation is required
Investigating long COVID claims requires a thorough and detailed approach:
- Confirm a COVID infection: Ensure that the insured party has had a confirmed COVID-19 infection and determine its severity (mild, moderate, severe).
- Review pre-existing conditions: Obtain up to five years of detailed medical history and records prior to the COVID diagnosis to assess pre-existing conditions that might be contributing to the long COVID symptoms.
- Gather post-COVID medical records: To understand the condition’s progression, collect all medical records post-COVID and long-COVID diagnoses.
- Consult treating physicians: Engage with the primary treating physician to assess the claimant’s ability to work, limitations, and the potential for an employer to make accommodations.
- Requisition an independent medical exam: Recognize that many long COVID symptoms are common in the general population. Some of the same health issues also can be stress-induced. An independent medical exam (IME) often is necessary to determine the disability’s true cause.
Long COVID claim numbers may be falling
Recent data compiled by KFF suggests that the incidence of long COVID may be diminishing. As of Jan. 2023, the percentage of people reporting long COVID symptoms has decreased over time, which underscores the need to stay up to date on evolving long COVID trends and statistics. As of:
- June 2022, 35% of COVID survivors reported long COVID symptoms.
- August 2022, 33% of survivors reported symptoms.
- October 2022, 30% reported symptoms.
- January 2023, 28% reported symptoms.
The percentage of adults reporting that they suffered from activity limitations due to long COVID, as of January 2023, broke along these lines:
- 27% experienced significant activity limitations.
- 52% had non-significant activity limitations.
Remember, however, that while its prevalence appears to be decreasing, long COVID remains a significant concern for COVID survivors and our industry.
Information changes almost daily
To date, we’ve handled a limited number of long COVID claims. They include those alleging disability due to COVID-related lung issues, pre-existing conditions exacerbated by COVID, and secondary health conditions linked to a prior COVID diagnosis. Most have been claims for total permanent disability. The adjustment process has been difficult and marked by uncertainty because we’re still learning about the condition and information changes almost daily.
The claims present unique challenges and opportunities
Long COVID claims pose unique challenges due to their nebulous nature. They require a thorough and transparent approach. Transparency is crucial in maintaining trust throughout the claims process, ensuring unbiased evaluations, and avoiding any undue influence on medical opinions. Though we must rely on independent exams, the number of individuals who possess the necessary expertise to confirm a diagnosis still is very limited.
Given the novelty of the disease, finding an IME can be challenging. Sometimes, due to a dearth of local specialists, we require experts who can travel long distances to conduct exams. Evaluating claim legitimacy can be complex, and pertinent medical expertise is essential.
Pay close attention to timing and reserving
Handling long COVID claims requires careful attention to timing. Some policies have elimination periods ranging from 90 to 180 days, during which the insured party must be unable to work due to their diagnosis. Educating claimants about the process timeframe is necessary to help manage their expectations.
Offer responsible claims support for an unresolved issue
Long COVID is a dynamic and evolving issue in the realm of insurance claims. As adjusters, we must remain vigilant, conduct thorough investigations, and maintain transparency throughout the process. To ensure a fair and equitable outcome for claimants, we’re responsible for keeping an open mind, remaining nimble, and adapting to this changing public health issue. By staying informed, empathetic, and committed to best practices, we can navigate the complexities of long COVID claims successfully, while offering policyholders the support they need during a challenging and confusing period in their lives.
Louis Pippin (lpippin@venbrook.com) is Chief Claims Officer at Venbrook Group, LLC. Melanie Thompson (mthompson@onesourcecms.com) is a Senior Claims Adjuster at OneSource Claims Management.
