Revised medical criteria for evaluating immune system disorders. Final rules

We are revising the criteria in the Listing of Impairments (the listings) that we use to evaluate claims involving immune system disorders. We apply these criteria when you claim benefits based on disability under title II and title XVI of the Social Security Act (the Act). The revisions reflect our adjudicative experience, as well as advances in medical knowledge, treatment, and methods of evaluating immune system disorders.

AAPL guideline for forensic evaluation of psychiatric disabilities: a disability law perspective

Contemporary disability law takes into account the insight that physical and mental conditions need not be disabling but for the environmental and attitudinal barriers that keep people with disabilities from social participation on a plane of equality with others. The need to use a wheelchair does not disable except for curbs and stairs, and many mental conditions do not disable except for social attitudes. The "AAPL Guideline for Forensic Evaluation of Psychiatric Disabilities" is a refreshing departure from writings that approach disability from a perspective that focuses on nothing but medical considerations and the study of how individuals are defective compared with established norms. The Guideline stresses the process of examination and list important legal considerations for examiners to apply. But the Guideline does not show any awareness of a model of disability other than a medical one that classifies individuals by defect. Psychiatrists would do well to consider the role of social barriers when using the Guideline in making disability-related examinations.

Recent developments in health insurance, life insurance, and disability insurance case law

This survey reviews significant state and federal court decisions from 2006 and 2007 involving health, life, and disability insurance. Also reviewed is a June 2008 Supreme Court decision in the disability insurance realm, affirming that a conflict of interest exists when an ERISA plan sponsor or insurer fulfills the dual role of determining plan benefits and paying those benefits but noting that the conflict is merely one factor in considering the legality of benefit denials. In addition, this years' survey includes compelling decisions in the life and health arena, including cases addressing statutory penalties and mandated benefits, as well as some ERISA decisions of note. This year, the Texas Supreme Court held that Texas's most recent version of the prompt payment statute abolished the common law interpleader exception and allowed the prevailing adverse claimant in an interpleader action filed beyond the sixty-day statutory period to recover statutory interest and attorney fees from the insurer. Meanwhile, the Court of Appeals of New York upheld the constitutionality of a statute mandating coverage for contraceptives in those employer-sponsored health plans that offer prescription drug coverage, including those plans sponsored by faith-based social service organizations. In the ERISA context, litigants continue to fight over the standard of review with varying results. In a unique assault on the arbitrary and capricious standard of review, the Fourth Circuit found that an ERISA plan abused its discretion when it failed to apply the doctrine of contra proferentem to construe ambiguous plan terms against itself. In more hopeful news for plan insurers, the Tenth Circuit held that claimants are not entitled to review and rebut medical opinions generated during the administrative appeal of a claim denial before a final decision is reached unless such reports contain new factual information.

Reasonable charges for medical care or services. Final rule

This final rule amends the Department of Veterans Affairs (VA) medical regulations concerning "reasonable charges" for medical care or services provided or furnished by VA to certain veterans for nonservice-connected disabilities. It changes the process for determining interim billing charges when a new Diagnosis Related Group (DRG) code or Current Procedural Terminology/Healthcare Common Procedure Coding System (CPT/HCPCS) code identifier is assigned to a particular type or item of medical care or service and VA has not yet established a charge for the new identifier. This process is designed to provide interim billing charges that are very close to what the new billing charges would be when the charges for the new identifiers are established in accordance with the regulations. This final rule also changes the regulations by removing all of the provisions for discounts of billed charges. This will eliminate or reduce duplicate discounting and thereby prevent unintended underpayments to the government.

Amendments to the quick disability determination process. Final rule

We are amending our regulations to extend the quick disability determination process (QDD), which is operating now in the Boston region, to all of the State disability determination services (DDSs). We also are removing from the QDD process the existing requirements that each State DDS maintain a separate QDD unit and that each case referred under QDD be adjudicated within 20 days. These actions stem from our continuing effort to improve our disability adjudication process.

Between health care and social security--psychiatric patients and the disability pension system in Norway and Russia

BACKGROUND

The official statistics of persons with mental disorders who are granted disability pension (DP) in Russia and Norway indicate large differences between the countries.

METHODS

This qualitative explorative hypothesis-generating study is based on text analysis of the laws, regulations and guidelines, and qualitative interviews of informants representing all the organisational elements of the DP systems in both countries.

RESULTS

The DP application process is initiated much later in Norway than in Russia, where a 3 year occupational rehabilitation and adequate treatment is mandatory before DP is granted. In Russia, two instances are responsible for preparing of the medical certification for DP, a patients medical doctor (PD) and a clinical expert commission (CEC) while there is one in Norway (PD). In Russia, the Bureau of Medical-Social Expertise is responsible for evaluation and granting of DP. In Norway, the local social insurance offices (SIO) are responsible for the DP application. Decisions are taken collectively in Russia, while the Norwegian PD and SIO officer often take decisions alone. In Russia, the medical criterion is the decisive one, while rehabilitation and treatment criteria are given priority in Norway. The size of the DP in Norway is enough to cover of subsistences expenditure, while the Russian DP is less than the level required for minimum subsistence.

CONCLUSION

There were noteworthy differences in the time frame, organisation model and process leading to a DP in the two countries. These differences may explain why so few patients with less severe mental disorders receive a DP in Russia. This fact, in combination with the size of the DP, may hamper reforms of the mental health care system in Russia.

[Fibromyalgia: how to appreciate work capacity?]

Fibromyalgia is a chronic pain syndrome of which there remains difficult to evaluate the functional repercussion. As in other affections without, or with weak shown organic substrate, the evaluation of the work capacity requires a rigorous approach, which adopts an integrative bio-psycho-social model. Diagnostic classification poses problems insofar as the same syndromic association can result in different diagnoses. The object of this article is to highlight some difficulties related to the coexistence of medical and legal logics which can sometimes be divergent. Generalization, on the legal and administrative side, of simple dichotomic rules, must in no manner lead the physician to make the saving of taking into account the complexity.

Extension of the expiration data for several body system listings. Final rule

We use the Listing of Impairments (the listings) at the third step of the sequential evaluation process when we evaluate your claim for benefits based on disability under title II and title XVI of the Social Security Act (the Act). This final rule extends until July 1, 2008, the date on which the listings for eight body systems will no longer be effective. Other than extending the effective date of the listings, we have made no revisions to the listings; they remain the same as they now appear in the Code of Federal Regulations. This extension will ensure that we continue to have the medical evaluation criteria in the listings to adjudicate disability claims involving these body systems at the third step of the sequential evaluation process.