Insurers frequently deny disability benefits based on the lack of “objective medical evidence.” This can make or break your claim.
Our video begins with a reminder that disability insurance companies are always looking for ways to reduce their liability. They want to cut costs, and so have developed strategies and tactics by which they are able to reduce long term disability benefits – and even deny benefits altogether, or terminate existing benefits.
One practice insurers often use is to continually ask you for objective medical evidence of disability. This strategy works particularly well if a disability is based on self-reported symptoms – symptoms that only you, the claimant, can perceive, such as dizziness or pain.
What is a Self-Reported Symptom Limitation?
Some policies have provisions that restrict benefits for self-reported symptoms (as opposed to symptoms supported by objective medical evidence). These are known as self-reported symptom limitations. Exclusions and limitations such as these are common in group disability insurance plans. Governed by federal ERISA law, group disability plans are not individually underwritten, and remedies available to claimants are narrow.
If your LTD claim is based on self-reported symptoms, what are these policy limitations and how do they affect you?
The insurer may accept that you have become disabled, but because of the self-reported symptom limitation clause, once the policy threshold is met the disability payments end. This threshold generally is a 24-month period, meaning the insurance company will pay benefits for 24 months, and that is all.
The following is an example of how a self-reported symptom limitation provision is worded:
Disabilities, due to sickness or injury, which are primarily based on self-reported symptoms, and disabilities due to mental illness, alcoholism or drug abuse have a limited pay period up to 24 months.
Self-reported symptoms means the manifestations of your condition which you tell your doctor that are not verifiable using tests, procedures or clinical examinations standardly accepted in the practice of medicine. Examples of self-reported symptoms include, but are not limited to headaches, pain, fatigue, stiffness, soreness, ringing in ears, dizziness, numbness and loss of energy.
This clause is often followed in the disability policy with another provision requiring that you must supply objective evidence as proof of your disability.
What Is Objective Medical Evidence of Disability?
Objective evidence generally refers to diagnostic tests – procedures that are known to establish evidence of your disease or condition. The results of objective medical evidence are always discernable and can be quantified.
Common examples include:
- Imaging tests such as CT scans, MRIs or X-rays,
- Electrocardiogram (ECG or EKG) to evaluate coronary artery disease or heart rhythm issues
- Nerve conduction studies such as electromyography (EMG) to measure the efficiency of a patient’s nerves to transmit electrical signals to the muscles
- Laboratory findings such as blood testing, pulse rate, blood pressure and chemical levels.
- Pathological findings such as biopsies
- Mammography to detect breast cancer
- Spinal tap to diagnose infections and neurological conditions
- Electroencephalogram (EEG) to confirm and record the brain’s electrical activity to diagnose head injuries, epilepsy, brain tumors and more
These and many other diagnostic tests produce objective findings of physical, neurological, cognitive and psychiatric disorders.
Not All Diseases and Impairments Have Objective Medical Evidence as Proof of Disability
If there is no objective evidence to substantiate and quantify the fatigue, pain or other self-reported symptoms you are experiencing, what can you do?
The insurance companies find it easy to allege that without objective medical evidence of your condition, or of the degree of your impairment, your case is not credible.
This becomes critical to patients who suffer from symptoms that are difficult to diagnose, like headaches, fatigue or vertigo, and victims of diseases such as multiple sclerosis, chronic fatigue syndrome and fibromyalgia – where the symptoms are difficult if not impossible to observe and quantify through “objective” testing procedures.
The Insurance Company Does Not Hold All the Cards
Our disability attorneys are prepared for these tactics taken by insurance providers. Clinical tests aren’t the only thing that can provide objective proof of disability. We can often produce objective evidence by examining the physical limitations caused by your disorder. We accomplish this through a functional capacity evaluation (FCE) – tests that evaluate the degree of your impairment in light of your physical capabilities.
In cases of cognitive dysfunction or psychological disabilities, such as Alzheimer’s, brain injury or stroke, a neuropsychological examination can provide very valuable objective evidence.
Other times we are able to establish that a particular condition can only be confirmed through subjective, non-objective factors – and in these cases, requiring objective medical evidence of that impairment is an abuse of discretion.
Disability insurers deny benefits at the most distressing times in a person’s life. If you would like assistance with your disability appeal, let us help. Please contact us today and ask for a Free Case Evaluation.