Long Term Disability Law Blog
In this video and article gain insight into the most common medical reasons for a disability insurance claim. Disability insurance attorneys Rachel Alters, Gregory Dell and Cesar Gavidia discuss the TOP 5 Common Disability Insurance Claim Conditions. For an extensive review of your disability insurance company visit Diattorney.com for more information on applying for disability insurance benefits, appeals, denials, lawsuits, and buyouts.
GREGORY DELL: Hi, I’m Greg Dell with attorneys Dell and Schaefer. And I’m here with attorneys Rachel Alters and Cesar Gavidia. And today’s question or topic we’re going to discuss is the most common causes, medical conditions of a disability claim. And there are top 10 lists out there from all kinds of different sources, and I pulled one. And I wanted to get your guys’ opinions and maybe talk about some of the issues.
We can’t really go through the top 10 and the issues associated with that because then this video would be about three hours long. So we’ll scratch the surface on them and– and maybe just talk about some of the things that people should be aware of if they happen to have one of those particular conditions that is something immediately just to plant a seed in their mind. And then we do have other videos where we talk about the specific medical conditions.
And of course, we welcome anyone to call us to discuss their medical condition and how that relates to a specific claim because we’ve seen– I mean, we’ve seen every type of medical condition. So we’ve become “quasi” doctors in a sense because we have to really understand these conditions in order to properly present them.
So I guess we’ll go– do this like a like a Family Feud since I haven’t told you beforehand what’s on the list. But there was a top 10 list. So Rachel, what comes to your mind off the top of your head for the most common medical condition that’s the cause of a disability claim?
RACHEL ALTERS: And just from my experience alone over the years, I noticed that majority of my claimants, clients, have lumbar cervical issues. So a lot of them are suffering from herniated disks, people who have had fusions of the spine, cervical issues, a lot of people who have difficulty sitting for long periods because they’re in pain due to their bad condition. So I find that a lot of my claimants have back and cervical issues. That tends to be a very common issue that’s causing people to– because a lot of people sit at a desk for their job. And sitting causes pain in a lot of these claimants.
GREGORY DELL: And in the disability world, those have become known as musculoskeletal disorders because they deal with the skeleton– well, obviously the skeleton and the muscles. So you’re basically saying spinal conditions, whether it’s neck, back, thoracic, lumbar, all of those regions. And Cesar when you hear about musculoskeletal, and because of the fact that is definitely in the top five of the types of claims, what have some carriers done to try to limit those types of claims?
CESAR GAVIDIA: Well, what you’re encountering now in– it’s not widespread, thankfully, but you’re starting to see it in some disability– it’s particularly group disability policies, is neuromusculoskeletal limitations. So if you suffer from a herniated disk or if you suffer from some sort of spinal– and they’ll say spinal condition, then your claim will not be paid beyond a certain period of time. Usually, it’s 24 months.
Sometimes there’s exceptions. So they’ll say if you have radiculopathy, which is basically numbness, tingling, nerve symptoms going down into your extremities, into your hands, into your legs, into your feet, in your arms, then that could be an exception. In other cases where there’s evidence through an MRI of a certain compression on a nerve, or in your spinal cord, or something like that, then there’s an exception. So there are sometimes work arounds, but it’s not something we like to see.
Clearly, it’s discriminating against certain types of disabling conditions. It’s obvious why they do that. Those are very commonly-sought disabilities. So their reaction, the insurance companies’ response and reaction to these disability claims are so common is to say, we’re going to limit our exposure. And by providing this limitation in your policy, we’re not going to have to pay so long.
GREGORY DELL: Right. And the reason for that, Rachel, and you brought up spinal conditions, is because everybody, especially over the age of 40, has what’s called degenerative disk disease in your spine. It’s just the way it happens. You get bone spurs, which are also known as osteophytes on the spine.
And you don’t necessarily have a herniated disk, but you start to get those impingements, which is why maybe going through your 20s and even your young 30s, you never had back pain, and then all of a sudden you’re in your 40s, and you wake up or you do something weird and your back hurts. And then maybe it becomes chronic, and it comes it goes, but then it gets worse and worse. So they’re aware of that, same with the neck and everything else. So the longer on this world, the more exposure you’ve had to just being around and doing things and injuries or things like that.
So spinal conditions, number one. Cesar, I’ll pitch to you for number two most common cause of disability claims.
CESAR GAVIDIA: Well, you were touching on the limitations. But what came to mind was mental health issues, depression, anxiety claims, post-traumatic stress disorder claims, bipolar claims. That range of psychiatric conditions is very, very common in terms of disability claims. Those are the types of things that may have been in someone’s medical history for quite some time. With different triggers and stressors, those things can get worse.
And the way I see it, and I know the way we all see it, is that mental health claims are just as disabling as physical. Mental health issues are just as disabling as physical disabilities. But that’s probably the second most common form of disabling condition or claim that we’ve seen.
GREGORY DELL: Not only are they just as disabling, but I would say more often than not, you have a physical claim that has secondary mental health conditions. Because I know just when I’ve injured my knee in the past, and I’m someone who likes to run a lot, if I’m not able to run, or do my exercise, or go play tennis, or do activities with my kids or my friends, it gets depressing.
I don’t know if I’m clinically depressed. But it’s– a change in your lifestyle has an effect. And then that starts to affect– it affects your relationships. It affects your ability to do your work. So now your pain– and a lot of times it’s the pain that’s causing you to have what starts to become–
CESAR GAVIDIA: Comorbidities
GREGORY DELL: Yeah, the comorbidity, unfortunately, Rachel, talk about how it can be a limit for someone’s claim if the insurance company tries to make the depression, anxiety, or cognitive difficulties that start to develop from your pain as the primary cause of limitation versus the physical. Why could that be a problem for someone’s claim?
RACHEL ALTERS: And unfortunately, it’s often a problem. And I get these calls all the time where the insurance carrier sees the opportunity to turn a claim that is essentially primarily a physical disability into a mental nervous claim because probably 99% of the group policies have a 24-month limitation for any mental nervous claim. So the insurance companies seize the opportunity to save money right there immediately.
So what they do is they will focus– and a lot of claimants will tell me, I’ve talked to the insurance adjuster, I told them that I have a severe back injury, and the back injury’s the reason that I can’t work. But all they’re asking me for is my psychiatric record and my psychotherapy records.
They don’t want the records from my orthopedic. Why is it that they’re doing that? And I said because they’re trying to make this mental nervous claim so they only have to pay you for 24 months. It happens all the time.
So what we have to do is we have to jump in and make sure that we focus the disability claim on the physical because the physical claims can and will pay up to age 65 or greater to retirement age if there is enough evidence in the records to prove that your physical claim is disabling. So we have to refocus the insurance company.
And it’s not an easy task because a lot of times they will– especially if there is a pre-existing anxiety and depression issue, and that’s not a disabling– it’s not a disabling illness, but they will turn it into one so that they only have to pay them for 24 months. So it is a lot of work, but we do it all the time.
GREGORY DELL: So Rachel, the next most common one, which I know– well, not necessary in order, but definitely in the top five would be nervous system disorders– multiple sclerosis, Parkinson’s, conditions like that. I don’t know that the fibromyalgias of the world, those diagnoses fall in there, but often they’re seeing a rheumatologist, they may see a neurologist, all of the conditions that you’d go to a neurologist for.
And more often than not, those can be– those are progressive diseases. And those claims can be very difficult. Can you just briefly touch on why are they difficult claims when trying to get approved or win an appeal?
RACHEL ALTERS: Oftentimes– and I have a lot of claimants who have multiple sclerosis and have Parkinson’s. And unfortunately, a lot of them have been denied from the initial application process, even if they– they’re not– the insurance carrier is not denying that they have multiple sclerosis, but they’re denying that the MS is disabling.
So what they do is they say, well, yeah, we do agree that you’ve been diagnosed with relapsing, remitting multiple sclerosis, but you haven’t had a relapse in a very long time. And we think that your restrictions or limitations aren’t such that prevent you from being able to do your job. So they think, we think you can work with the MS. And oftentimes, we have to work with the neurologist very closely to get them to do further testing, to make sure that they’re documenting what is really going on with this claimant.
Because a lot of claimants, not only do they have physical issues with MS because MS can be disabling physically with your muscles, people get fatigue, but cognitively they’re affected. And that’s not something you can just see by looking at a claimant. You have to sometimes send somebody for a neuropsychological evaluation to determine if there’s cognitive dysfunction related to the MS. And oftentimes there is, but the insurance carriers will sometimes stand their ground and say, well, we think you can still work with this condition. And that goes for Parkinson’s as well.
GREGORY DELL: And then Cesar, we were– we talked earlier in a video that we filmed the other day about, especially with these nervous system conditions, well, you’ve had that diagnosis for, sometimes with MS, 10 years or more. And you’ve been working. And you haven’t missed a lot of work.
And nobody wants to leave their work. I mean, most of these– most of our clients– nobody’s looking to leave. They don’t get more money on disability. Especially in the group world, you’re always getting less.
So how do you address that, Cesar? Because almost every nervous system disorder claim is a chronic treatment and diagnosis, and now you get to the point where you can’t work anymore. But the carrier says, oh, you’ve worked.
CESAR GAVIDIA: So basically they’re falling back on their classic defense or argument that there hasn’t been a progression of your condition to justify now these limitations that are being placed on you that you couldn’t work. And it really goes back to doing a real comprehensive review and analysis of your medical records and of your medical history and also really developing your doctor and expert support to establish that there may have been– I mean, it doesn’t even always have to be necessarily a critical, substantial change in your condition.
Perhaps it’s something that substantially changed with your occupation. Maybe something– and it could be any particular thing, a new task, a new responsibility, or working differently. There’s things that trigger things like multiple sclerosis, that trigger these conditions that cause a flare or cause things to progressively worsen. So we have to work with our clients and with our clients’ doctors to ensure that this is all being appropriately addressed and documented in their medical records.
GREGORY DELL: So I want to go next to– and Cesar you’ll– cancer. Cancer has unfortunately become common as a diagnosis. It’s usually not– if someone’s going to get it, it’s when. But cancer nowadays, more so than years ago, is very treatable.
And most of our clients, obviously, they get the diagnosis. And we talked about this return to work. There’s a return to work models for if you have cancer you go back to work.
But there are a handful of people who have this diagnosis and aren’t able to return to work, the things like chemo brain, chemo fog, cognitive difficulties, functional limitations, the mental nervous component of it. How do you address those? Because more often than not, we see, yes, we don’t dispute your diagnosis. There’s no disputing a cancer diagnosis.
CESAR GAVIDIA: Right. And the thing I found particularly with those treatment-related disability claims, when someone’s like in remission or they’re going through– they’ve gone through the chemo treatment, now they’re in remission, but they still continue to have fatigue, weakness, you have to remember that these medications that they’re giving you to treat your cancer, they’re basically poisoning your body to get the cancer out. And it’s taking a substantial toll on you. And sometimes those residual effects can last your entire life.
The problem is in terms of a lot of the claims that we’ve seen that have been denied on the basis of those treatment– cancer-related treatment claims is that the medical documentation, the medical records aren’t usually effectively or properly documenting or recording how impactful, how significant, and so how substantial the impairments are from the residual effects of that medication or from the treatment. So it’s– and sometimes–
GREGORY DELL: Because the medical records were geared towards, we got to kill the cancer.
CESAR GAVIDIA: Right.
RACHEL ALTERS: It’s saving your life.
GREGORY DELL: We’ve got to get this person into remission. And then when the person’s in remission, which is more often than not the case, which is fantastic, they’re not so worried about, oh, you’re fatigued, or oh, you can’t sit for two hours at a time.
CESAR GAVIDIA: And what does the doctor do for it? The doctor’s just going to basically say, well, don’t do things that cause you to be fatigued or try to rest. So there’s not really an appropriate treatment plan. And like you said, the doctor’s just geared to curing your cancer and saving your life.
GREGORY DELL: So that’s why more often than not– and again, we’re just touching on these topics as you potentially move away from the oncologist as a supporting doctor and move to maybe an internal medicine or general practitioner-type doctor who’s now going to deal with your day-to-day type issues and help you. But it’s surprising how many cancer disability denial claims– look, in the beginning, you have cancer, you file short-term disability, you’re going to get– you’re going to get approved–
CESAR GAVIDIA: Right.
GREGORY DELL: –especially if you’re going through a surgery or a chemo. But shortly after that, you should expect that you’re going to have a hard time. And more often than not, if you’re out for 90 days, you’re getting terminated from your job.
CESAR GAVIDIA: Right.
GREGORY DELL: That’s how most of– especially most of these disability policies are bigger companies. So you have to be thinking about protecting yourself and whether or not you’re ever going to be able to get back to the level you used to be at.
But along those same lines, Rachel, I want to pitch to you heart disease. Cardiac disease is tremendous. It’s a big condition. And we see a lot of claims with it.
And a lot of people have a heart attack, or they have a heart surgery, or they have an angiogram, or some kind of procedure, or they just have chronic blood– tons of different cardiac issues that you’ve seen. But yet those claims are, unfortunately, more often than not, denied. And a lot of them are, yeah, you had a heart– even if they had surgery, they expect you back in 60 days.
And the cardiologist says you’re OK. But OK means you’re not going to have another heart attack now, and you’re not going to die. And more often than not they say, avoid stressful situations. So does that become a mental nervous claim, or is that a cardiac claim?
RACHEL ALTERS: Well, it’s confusing because a lot of people will call and they’ll say, I had a heart attack, I had open heart surgery, I was out of work for eight weeks, my doctor has told me not to go back to work because, number one, I’m very fatigued because people who have heart conditions tend to fatigue very easily.
They don’t want me in a stressful situation because my work is very stressful. And stress can cause me another heart attack. And whatever the other reasons why the doctors put them out of work.
And they say, but my insurance carrier says I’m fine to go back. So, what do I do because, number one, they’re scared to go back to work. And number two, they’re probably not in any condition because if they’re fatigue, they can’t focus. Depending on what kind of medications the doctor have put them on, it can cause them side effects, which make it very difficult for people to work.
So I think it’s– you can work with the cardiologists. And the problem is yes, if they go in for testing, it depends. Some people– I know have a lot of clients who have very low ejection fractions. And if they have a very low ejection fraction, they are at a very high risk for another event.
But if all of these things are normal, and their EKGs are normal, their echocardiogram come out normal, their ejection fraction looks OK, then the insurance carrier looks at those objective tests and say, well, we think he’s fine to go back to work when in essence they’re not. It’s very hard to prove that having a stressful situation that could become another cardiac event is a disability. It’s a hard thing to get a carrier to buy. You have to work with the doctors to document in such a way that they’re saying that it is detrimental to their health if they go back to work. And they have to put in other reasons why as well.
GREGORY DELL: But people need to understand, especially with heart conditions, like they have the classes, you either have a class A, B, C, or D or a class 1 through 4 criteria, and you mentioned ejection fraction, like in social security, if you’re less than 25%, they automatically approve you. Well, I have a client getting $10,000 a month from Sun Life who was getting paid for seven or eight years. He was an OB/GYN. His ejection fraction rate’s 20%.
It’s been that way. He’s genetically had a low ejection fraction. They paid him for seven to eight years, and then basically say, well, you’re doing OK. We’re not going to pay you anymore.
But they expected him to go back to work, go back to being an OB/GYN, expecting him to be up all night delivering babies. And he’s like, look, after an hour or so, I’m fatigued, and I don’t want to subject myself to having to be committed to a schedule, having to be there to deliver a baby or whatever I’m doing. And I have modified my lifestyle to keep myself where I’m not getting worse.
And they’ve been like, well, you didn’t have any episodes. He has a pacemaker. Your pacemaker didn’t trigger. Well, so they’re basically saying, since you’ve been stable, we think you’re better.
RACHEL ALTERS: But he’s stable because he’s not stressed.
GREGORY DELL: Right. To the disability carriers, stability means you’re better. So it’s like this unwritten rule that if you’re not getting worse or you’re not deteriorating, then we think you’re potentially better. And therefore, we think you’re ready to go back to work, which is completely unrealistic.
So, there’s a lot more conditions to talk about. And we’ve seen so many. I know, Rachel, you do a lot with Lyme, and fibromyalgia, and a lot of those subjective-type claims where there’s just no testing to prove those types of claims, which can also be very difficult.
But no matter what it is, I always recommend for claimants to call us. If they’ve been denied, send their denial letter. If they have the policy and they’re considering applying, no matter what’s going on with the claimer, you feel like you’re going to be denied, reach out to any of us.
We’ll always provide you with a free initial consultation. We’ll discuss how we can help you. We represent claimants all over the country. And we really encourage you to go through our website or our YouTube channel if you came through that way.
Subscribe to our YouTube videos because every week we’re putting out new videos where we’re talking about different types of medical issues, different types of claim healing techniques. And most importantly, search our website by your company because you’ll specifically find great information that will hopefully keep you on claim or help you get through a claim denial. We look forward to the opportunity to help you in the future.