Long-term Disability Applications and Denials

When I get calls from people saying they have been denied long-term disability benefits, the most likely reason is insufficient medical information. 

 

Insurers need to satisfy themselves that the medical information supports payment of disability benefits under the applicable definition.  Previous blogs have discussed the 2 main definitions but to quickly summarize; usually there is a period of 2 years where one must be disabled from performing the essential duties of their own occupation in order to receive disability benefits.

After the expiration of the “own-occupation” period, the test for disability usually becomes the inability to perform the essential duties of any reasonable occupation based on your training, education or experience.

 

It is imperative you check your specific long-term disability policies for the specific definitions of long-term disability and the various periods of payments.  

 

Applications for disability benefits are frequently made up of 3 forms:  the initial application which is made by the claimant; the employer’s statement which provides details of job history, duties, pay, etc.; and the Attending Physician’s Statement which is the primary form the insurer looks at when determining whether to grant disability benefits.

 

I find most applications are denied because the insurer does not find the Physician’s Statement satisfactory.

 

To be clear, this is not a slight upon the physicians filling out the forms.  They answer the questions that are asked.  In my experience, the fault tends to lie with the insurer which does not provide any clarification with specifically what is required.  Further, the forms are usually short answer, fill in the blank, type queries that do not lend themselves to full answers in such a short format.

 

The constrained format of the Physician’s Statement coupled with the lack of explanation to the doctor, usually results in a disability denial for insufficient medical information even though the doctor is very supportive of the claimant and filled out the Statement to the best of their ability.

 

The problem usually arises because the Statement only allows a summary of treatment, diagnoses, limitations and prognosis.  This means the doctor filling out the Statement, uses “labels” such as depression, fibromyalgia, chronic fatigue, Lyme disease instead of spending time focussing on the symptoms and functional limitations caused by the diagnosis.  I tell people who call me for advice to get the doctor to describe why you cannot work without ever using the term “disabled”.

 

For many doctors, the focus of their patient care is finding out what is wrong with their patient.  If they can get to a diagnosis, then they can formulate a plan to start treatment.  For disability law, the primary focus is usually on functional limitations first and diagnosis second.

 

Remember, a person with a diagnosis of cancer with no limitations will not qualify for the standard disability benefits insurance; however, a person who is bed-ridden with an unknown diagnosis will usually be able to obtain disability benefits.  As discussed in my previous blog, it is not what you have, but rather how it affects you that is important.

 

When the doctor completes their Physician’s Statement, they are free to provide extra clarification in the form of additional pages and attachments to the Statement.  However, most doctors cannot afford to take the time to fill out the Statement with that level of detail.  Insurance companies do not pay the doctor for the Statement completion – and most doctors do not charge their patients – or if they do, the amount is minimal.

 

The doctor filling out the Physician’s Statement can provide the claimant the best chance of being accepted by the insurance company if they focus on how the disease, illness or injury is causing the patient to suffer functional limitations and how those limitations affect their day-to-day activity and their work duties.

 

Further, if the claimant is receiving any medications or treatments which have side effects, then those should also be discussed.  The assessment of functional limitations to get disability benefits is not limited to a particular body part or diagnosis.  It is more of a consideration of the entire person including any conditions which may, by themselves, not be disabling, but in the presence of some other condition, even if it is a minor condition, can cause the entire person to no longer be able to function at work.

 

For example, I have had clients who had heart disease but not to the severity that it prevented them from doing their own occupation.  However, when that same client contracted COVID, all of sudden, their heart disease became so symptomatic they could not even get out of bed.   There is no evidence that the virus responsible for COVID-19 directly infects the heart, however, the acute inflammatory response associated with COVID can create a lot of issues with compromised heart functioning.

 

Taken in isolation, my client was not disabled from heart disease, and it is unknown whether they would have been disabled solely from contracting COVID, but when the 2 morbidities were combined, the result is a person who is disabled and entitled to their disability insurance benefits.

 

Remember – obtaining disability benefits is not about labels but it is about limitations.  Make sure your doctor details them in the Physician’s Statement.

 

If you have questions about applying for long-term disability benefits or are having problems obtaining benefits from your insurance provider, please call me at 403-670-0055 (or toll-free 1-877-682-3476) and we can discuss the situation.

 

Until next time, stay safe.

 

James Ludwar

Ludwar Law Firm