As attorneys at Dell & Shaefer disability insurance law firm, we’ve seen just about every type of medical condition and are fully equipped to understand what’s involved to get paid your disability income benefits. Following is a glimpse of the five most common health issues leading to disability claims, as well as some essential things that disabled policyholders should know.
1. Lumbar Cervical Issues / Musculoskeletal Disorders
By far, the most frequent medical conditions in disability insurance claims involve lumbar cervical issues and musculoskeletal disorders. A vast number of claimants with lumbar cervical issues suffer from herniated disks and back issues, have had spine fusions, or have difficulty sitting for long periods of time due to pain. This becomes a serious issue when workers must sit at a desk in order to perform the functions of their jobs.
In the disability world, these medical issues have become known as musculoskeletal disorders because they deal with the skeleton and the muscles. They present as spinal conditions affecting the neck, back, and thoracic or lumbar regions. They aren’t even necessarily caused by a herniated disc or contributing injury, because many people over the age of 40 naturally have degenerative disc disease. This can cause bone spurs, which are also known as osteophytes on the spine.
Because this is such a common disabling condition, some disability insurance carriers have attempted to put a time limit on neuromusculoskeletal claims, even though it’s clearly discriminating. The limitation essentially states that with certain spinal conditions, your claim will not be paid beyond a specific period of time, typically 24 months.
2. Mental Health Issues
Mental health issues are just as disabling as physical disabilities. Psychiatric conditions can range from depression to anxiety, post-traumatic stress disorder, bipolar diagnosis, cognitive difficulties and many more. These things may have been in a person’s medical history for quite some time, but certain triggers and stressors cause things to worsen.
In addition, a person with a physical claim can easily have a secondary mental health condition. For example, a knee injury that limits the ability to exercise, jog, play tennis or engage in activities with your kids or friends can lead to depression. A lifestyle change like that starts to affect relationships and the ability to perform at a job, coupled with the pain from the original injury.
This brings up the issue of comorbidity, which is the presence of two chronic diseases or conditions at the same time. Unfortunately, an insurance company may try to limit a person’s claim by making the mental condition, rather than the physical one, the primary cause of the inability to work. Why does this matter?
This becomes a problem for the person’s disability claim because up to 99 percent of group policies have a 24-month limitation for any mental claim. That’s an immediate way for the insurance company to save a lot of money, and they’ll seize on that opportunity by focusing on psychiatric or psychotherapy records rather than orthopedic or other physical ones. At Dell & Schaefer, a disability insurance attorney will jump in and ensure the focus of the disability claim remains on the physical limitations that pay up to age 65 or to retirement age.
3. Nervous System Disorders
Holding a firm place in the Top 5 causes of disability claims are nervous system disorders, which include conditions such as multiple sclerosis and Parkinson’s disease. These are progressive diseases and tend to have difficulty getting disability benefit approval. Why is that?
“Claimants with multiple sclerosis and Parkinson’s have often been denied from the initial applications process,” explains disability lawyer Rachel Alters. “The insurance carrier is not denying they have MS, but they’re denying that the MS is disabling.”
The insurance carrier may agree that the worker has been diagnosed with relapsing, remitting multiple sclerosis but perhaps they haven’t had a relapse in a long time – leading to a determination that the claimant is in fact able to work. That’s when a competent disability attorney will work closely with the neurologist to do further testing and documentation that benefits the policyholder.
In addition to the physically disabling issues of MS or Parkinson’s, a lot of claimants are affected cognitively. That’s not immediately obvious when looking at the person, so it may require a neuropsychological evaluation to determine disease-related cognitive dysfunction. This can deter an insurance carrier from issuing a disability claim denial.
Because almost every nervous system disorder claim involves a chronic treatment and diagnosis, the worker may have had the disease for 10 years but then becomes unable to work anymore. But the insurance carrier argues that he’s consistently worked for 10 years, making a classic defense that there has been no disease progression that limits job performance. That’s why it’s crucial to do a comprehensive review and analysis of medical records and to develop doctor and expert support.
If there’s been a change in the disabled claimant’s condition, that needs to be documented, according to our Dell & Schaefer attorney Cesar Gavidia. Equally important is to note any changes in the occupational duties of the patient, such as a new task, responsibility or working condition that could trigger a flareup or disease progression.
There’s no disputing a cancer diagnosis. However, cancer has become very treatable these days, leading to disability disputes about whether patients are capable of returning to their jobs.
Though “return to work” models for cancer patients exist, some employees have severe limitations due to treatment procedures. They’ve gone through chemotherapy treatment and may have ongoing “chemo brain” or “chemo fog” along with cognitive difficulties, functional limitations, mental nervous issues fatigue and weakness. The residual effects of cancer and resulting treatments can cause residual effects that last a lifetime.
A big problem with cancer-related treatment claims is the lack of medical documentation. The doctor has been focused on killing the cancer and saving the person’s life, so when they enter the remission stage, there’s typically less effective documentation of the residual physical effects of the medication and treatment.
The impairments can be substantial and must be properly documented along with an appropriate treatment plan. As the patient moves from an oncologist to a supporting physician in internal medicine or a general practitioner, the medical records must chronicle the ongoing day-to-day issues that would affect the ability to perform in the workforce.
After the initial surgery or chemo treatment, it will be harder to justify disability with the insurance company and employer. It’s also possible to be terminated from your job after an absence of 90 days, so time is of the essence when establishing an inability to resume former work levels.
5. Heart Disease
Many disability claims resulting in an ERISA denial involve heart disease and cardiac conditions cause heart attacks, heart surgery, various cardiac procedures and chronic conditions. However, employees with cardiac issues, even after heart surgery, are often expected to return to the work force after 60 days.
A cardiologist may state that the surgery was successful, and the condition is under control, but that the patient must avoid stressful situations. Stress can lead to another heart attack, while the heart disease (and medications) can cause extreme fatigue – all of which affect a person’s ability to successfully perform in a work environment.
So, what happens when doctors instruct a patient not to resume working, but the disability insurance company says the patient is fine returning to the job?
A disability insurance law firm can work with the cardiologists to document testing in a way that establishes an ongoing detriment to the patient’s health if he resumes normal activity, including the stresses of job performance. Even if EKG tests or ejection fractions are normal, it’s crucial to document reasons why stressful situations can lead to another cardiac event.
The patient has likely modified behavior in order to become stable and prevent the cardiac condition from getting worse. But disability carriers attempt to interpret stability as meaning that the person is better as long as things are not deteriorating. Therefore, from their perspective, the disabled claimant is ready to resume working – which is completely unrealistic and can jeopardize long-term health.
Regardless of the type of disability claim you have, we recommend reaching out to us at Dell & Schaefer. We represent policyholders all over the country, always provide a free initial consultation, and look forward to hearing from you.