What You Need to Know About Functional Capacity Evaluations in Your Long-Term Disability Claim

Welcome to Season 4, Episode 44 of Winning Isn't Easy - our Season 4 finale. In this episode, we'll dive into the complicated topic of "What You Need to Know About Functional Capacity Evaluations in Your Long-Term Disability Claim."

Join host Nancy L. Cavey, a seasoned attorney with extensive experience in disability claims,  as she explores functional capacity evaluations. These evaluations assess an individual's physical abilities and can be valuable in determining disability and strengthening claims. However, they are also prone to common pitfalls and mistakes that can ultimately undermine a case. In this episode, Nancy will provide a detailed overview of functional capacity evaluations, explain their benefits, and highlight the key mistakes that can occur during the process. 

In this episode, we'll cover the following topics:

1 - The Nuts and Bolts of a Functional Capacity Evaluation

2 - How You Can Use a Functional Capacity Evaluation to Support Your Claim and Overcome a Wrongful Claim Denial or Termination of Benefits

3 - Seven Mistakes You Can Make during a Functional Capacity Evaluation Ordered by Your Long-Term Disability Carrier

4 - What Are the Seven Ways an ERISA Disability Carrier Will Use the Results of a Compulsory Functional Capacity Evaluation to Terminate Your Disability Benefits, and How You Can Protect Yourself

Whether you're a claimant, or simply seeking valuable insights into the disability claims landscape, this episode provides essential guidance to help you succeed in your journey. Don't miss it.


Resources Mentioned In This Episode:

LINK TO ROBBED OF YOUR PEACE OF MIND: https://caveylaw.com/get-free-reports/get-disability-book/

LINK TO THE DISABILITY INSURANCE CLAIM SURVIVAL GUIDE FOR PROFESSIONALS: https://caveylaw.com/get-free-reports/disability-insurance-claim-survival-guide-professionals/

FREE CONSULT LINK: https://caveylaw.com/contact-us/


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Please remember that the content shared is for informational purposes only, and should not replace personalized legal advice or guidance from qualified professionals.

Transcript

Nancy Cavey [00:00:15]:
 Hey, I'm Nancy Cavey. I'm a national ERISA and IDI disability attorney, and I want to welcome you to Winning Isn't Easy. Before we get started, I've got to give you a legal disclaimer. This podcast is not legal advice. The Florida Bar association says I have to say that. But now that I've said that, nothing will ever prevent me from giving you an easy to understand overview of the disability insurance world, the games that disability carriers play, and what you need to know to get the benefits you deserve. So, off we go. Now, when you apply for long term disability benefits, you have the burden to prove that you're disabled as those terms are defined in your policy or plan.
 
 Nancy Cavey [00:00:54]:
 Now, in most disability policies or plans, the definition of disability will change over the life of the policy or the plan. Initially, you have the burden to prove that you're unable to perform the material and substantial duties of your occupation. Now, there are two material terms that I just mentioned. The first is an inability to perform the material and substantial duties and occupation. Now, guess what? Unfortunately, there is no uniform definition of those two terms. And you actually have to go to the disability insurance policy or plan and see how those terms are defined. Because again, you've got to prove that you meet that standard of disability generally. And historically, after two years of the payment of your own occupation benefits, the standard of disability will change from an inability to do your own occupation to an inability to do any occupation.
 
 Nancy Cavey [00:01:48]:
 And again, you need to understand what that term means. But as a practical matter, you ultimately have to prove that you can't even do what's called a sedentary job. Now, as part of the analysis of your capacities, your physical capacities, the disability carrier or plan may say, you know, you have to undergo a functional capacity evaluation and you obviously need to read your policy or plan because sometimes they will say, we want you to have one, but the policy or plan doesn't require you to have one. But let's assume for the sake of this podcast that your policy or plan requires you to undergo a functional capacity evaluation. If you don't go, that in and of itself can be a reason for the denial of a claim. Now, the FCE is just one tool in the disability carrier plans denial toolbox. I think that if that happens, in other words, they say, we want you to have an fce, that's time for you to hire an attorney because they're looking for a reason to to deny or terminate your benefits. Now, I also want you to understand that as a policyholder or plan beneficiaries attorney.
 
 Nancy Cavey [00:03:00]:
 I turn that around and I use FCES to our advantage to overcome a claim denial or termination. You can see the issue of a functional capacity evaluation can be really crucial to getting or keeping your benefits. So I'm going to be talking about four things today. First, I'm going to talk about the nuts and bolts of a functional capacity evaluation. Number two, how you can use a functional capacity evaluation to support your claim and overcome a wrongful denial or termination. Then I'm going to talk about the seven mistakes that you can make during an FCE that's been ordered by your long term disability carrier plan. And I'm going to talk about the seven ways that the ERISA Discipline Carrier Plan are going to use the results of a compulsory functional capacity evaluation to terminate your benefits and what you can do to protect yourself. Let's take a break before we get started.
 
 Nancy Cavey [00:04:08]:
 Welcome back to Winning Isn't Easy. Let's talk about the nuts and bolts of a functional capacity evaluation. Now, the purpose of a functional capacity evaluation is to objectively measure and prove your physical work restrictions and limitations so that the carrier plan can determine whether you're capable of doing heavy work, medium work, light work or sedentary work. Now those terms, by the way, are defined under the terms of the Dictionary of Occupational Titles and are commonly used by disability carriers or plans to determine not only the level of your past work, but the level of any other work they think you might be capable of performing based on the any occupation standard. Now, once the disability carrier determines what they think your level of physical functioning is, the question then becomes from a vocational standpoint, can you do your own occupation if you're at the own occupation stage, or can you do any other occupation from a vocational standpoint? And courts have considered, by the way, the functional capacity evaluation to be a gold standard test for objectively measuring and proving restrictions and limitations, notwithstanding what your doctor or their doctors have to say. So who performs a functional capacity evaluation? A functional capacity evaluation is typically performed by a licensed healthcare professional, such as a physical therapist, occupational therapist, or a physician. However, it's not uncommon for physical therapy assistants to perform the testing at the doctor or physical therapist's request and they aren't present, but they will sign off on the assistance findings. That's one of the tricks that disability carriers or plans will use to deny or terminate benefits.
 
 Nancy Cavey [00:05:51]:
 One of the first things we do when we see that type of game going on is we look to see how many signatures there are on the functional capacity evaluation and who was Present and who is not present. What happens during a functional capacity evaluation? Well, typically the FCE provider will be given your medical records in advance. They'll see what your work history is and they'll have a description of your occupational duties. Most likely at the beginning of the assessment, the physical therapist, the occupational therapist, the physical therapy assistant or the doctor will conduct an interview. They're going to ask questions about your medical background, your current diagnosis, your symptoms, your treatment, your response to the treatment, whether you've taken any medication before the fce. They may also ask you to take some psychological testing to determine your pain thresholds and whether they are out of proportion to what's commonly accepted or whether you're over reporting your symptoms. Now, at my law firm, we request any paperwork be supplied to us in advance and be advised of any testing that's going to be done, particularly of a psychological nature. We're going to obviously prepare you for what's going to happen at the functional capacity evaluation, help fill out the forms, and certainly we will object to any psychological testing that they want to have you undergo as part of this functional capacity evaluation.
 
 Nancy Cavey [00:07:14]:
 Now, you're going to be asked to perform a range of physical activities and tasks such as lifting, carrying, pushing, pulling, bending, stooping, twisting, turning, and the manipulation of objects. Generally, you're going to be asked to wear a heart monitor which is going to be used to determine if you're giving full effort or not. If the heart monitor shows you're not giving full effort or you refuse the testing, the disability carrier may simply deny your claim on the basis that you haven't given full effort and you haven't cooperated with the testing as required by the terms of your policy or plan. The functional capacity evaluator is also going to be watching you. They'll observe your posture, the mechanics of your body movements, and any difficulties you may have as you engage in these repetitive motions. They're also going to note how your symptoms change and the heart rate monitor readings should obviously increase as your pain level increases. When your heart rate increases because of increasing pain, the FCE provider will consider that to be legitimate evidence of pain because heart rate can't be faked. Now, you need to understand that there are several different types of functional capacity evaluation tests.
 
 Nancy Cavey [00:08:25]:
 In my view, they have to be scientifically valid and reliable to be admitted to into evidence in any court proceeding. And there have been times when I've actually challenged an FCE as not being scientifically valid or reliable. The evaluation is also going to document your pain and fatigue levels and they'll have symptom, rather validity testing to ensure that you're not only giving maximum effort, but that the results are accurate. Don't be surprised if the disability carrier or plan questions the results of an FCE on the basis that you haven't given full effort, that any positive testing indicates that you would be unable to perform your own occupation or the conclusions of the FCE if it doesn't comport with their goals. So they will actually try to take apart their own FCE if they don't like the results. Also, don't be surprised if there's surveillance on you the day before you go to the functional capacity evaluation, the FCE day and the day after. Why? Well, because they're going to try to catch you doing something you said you couldn't do during the FCE the day before or the day after. Now, I want you to be aware that many times people are going to be in pain after the FCE and they will limit their activities.
 
 Nancy Cavey [00:09:49]:
 So if you're reporting, hey, look, I'm in pain, I'm having difficulties as a result of this fce. And the day after the FCE they have surveillance of you doing something you said you couldn't because of that increased pain, that's going to be a problem for you and could result in a claim denial or termination. So you need to understand that surveillance can be part of their denial game in conjunction with the fce. How long does a functional capacity evaluation last? Well, it depends how long the FCE lasts, depends on the complexity of your medical condition and the nature of the testing being performed. Commonly, an FCE will last about four to five hours, half a day. In the case of chronic fatigue, it could be a two day fce. Now, I know that an FCE for two days can be really taxing, but it can help measure your sustained functionality over an extended period of time. The impact fatigue has both physically and cognitively.
 
 Nancy Cavey [00:10:51]:
 And it can demonstrate why you might not be able to meet the demands of a regular or full time schedule meeting the pace and production requirements. So there are times when a two day FCE is appropriate. Who pays for that functional capacity evaluation? Well, if the disability carrier plan is requesting that you undergo the fce, they're going to be paying for the fce. You can be assured that they're going to be using a captive vendor who is going to give them what they want because they want to have repeat business. I mean, you understand that. So you can expect that there's going to be bias because of who's paying for it. Now, on the other hand, if we're requesting a functional capacity evaluation, your health insurance company may cover it. Not all of them do, and otherwise the cost, of course, will be borne by you or if you're represented, potentially your attorney.
 
 Nancy Cavey [00:11:49]:
 And the cost is going to depend on the length of the fce, the complexity of the fce, the number of medical records they have to review, and the nature of the testing that you or your lawyer wants performed. There are times when I want the FCE provider to to basically simulate what my client's own occupation duties were as part of the FCE to prove that they can't do that. Got it. Now that we've established the basics of the fce, let's take a break and in the next segment I'm going to talk about how you can use an FCE to support your claim and overcome a wrongful claim denial or termination. Let's take a break.
 
 Speaker B [00:12:28]:
 Robbed of your peace of mind by your disability insurance carrier, you owe it to yourself to get a copy of Robbed of your peace of Mind, which provides you with everything you need to know about the long term disability claims process. Request your free copy of the book@kvlaw.com today.
 
 Nancy Cavey [00:13:13]:
 Welcome back to Winning isn't Easy how you can use a functional capacity evaluation test to support your claim and overcome a wrongful claim, denial or termination. Now, if your ERISA disability carrier or plan has denied your claim or terminated your benefits, you're only going to have 180 days in which to file an appeal. The appeal is the trial of your case. But before you get started, you want to get a copy of the carrier or plans claims file. Why? Well, you want to see a copy of that fce. You want to see how their physicians review the FCE and concluded whatever they think your restrictions and limitations might be and what those restrictions and limitations mean in terms of your functionality, they're also going to have a vocational evaluator who will have taken that information and rendered an opinion as to whether you can do your own occupation or any occupation. So you want all of this before you go about designing an attack on the results of the fce. So what do I mean by that? We also want to be able to tell our functional capacity evaluator everything that's going on.
 
 Nancy Cavey [00:14:25]:
 We want to tell them what the adjuster's thinking was, what the FCE provider report says, what their doctors say about it, and what the vocational evaluator that the carrier plan used concluded about your ability to do your own or any occupation. But there's also something else. If there's surveillance on you, we want a copy of that surveillance because we want our vocational evaluator to weigh in on it after the functional capacity evaluator has weighed in on it. So we want to understand the whole range of information that they've had. So when we retain a functional capacity evaluator to assist us in a case, we are going to be forwarding your medical records, the disability carrier plan's liar for hire medical records and opinions, the carrier's functional capacity evaluation, a copy of the occupational description of your occupation. If you're in the own occupation stage, if you're at the any occupation stage, we want to provide them with the occupational description from the Dictionary of Occupational Titles that the vocational evaluator is saying that you could do. And obviously we want to forward a copy of the vocational evaluators report so they understand how that evaluator took those restrictions and came up with these jobs. Now, obviously I'm going to be asking the FCE provider to do appropriate testing in the course of the FCE to simulate occupational duties that you performed or are based on the occupations that the vocational evaluator identified.
 
 Nancy Cavey [00:16:11]:
 So remember, you've ensured your occupation, not your job. So we want to simulate those duties as described in the Dictionary of Occupational Titles. Additionally, we want the FCE provider to tell us, are there any other testing or tests that you want to do to help address one, what our client's restrictions and limitations are, two, rebut that fce and three, rebut their vocational conclusions about your ability to do your own occupation or any occupation. Many courts have found that FCEs are the gold standard for assessing functionality if properly conducted. Now they can even be more reliable and valid, if you will, then an orthopedic examination or a liar for hire medical review. So it's important to understand the scope of why an FCE is important. The fce, unlike a physical exam, is testing your occupational abilities and measuring your ability to do occupational duties as opposed to just a pure physical examination. Now, the FCE can be useful if your physician is refusing to complete an attending physician statement form or to address objections of the carrier's fce, or in those instances in which your doctor just doesn't support your claim.
 
 Nancy Cavey [00:17:43]:
 So we use these for a number of purposes because the FCE can help your doctor confirm the restrictions limitations and help the doctor feel more comfortable addressing restrictions and limitations. So you can see that FCEs can be very important in combating a carrier's denial or termination of benefits or even to contest their liar for hire doctor's conclusions about your restrictions and limitations. But it's got to be used in conjunction with a vocational evaluation. Got it. Let's take a break. In our next segment, I'm going to talk about the seven mistakes that you can make during an FCE that's been ordered by your long term disability carrier plan. SA welcome back to Winning Isn't Easy. Let's talk about the seven mistakes that you can make during a functional capacity evaluation that's been ordered by your long term disability carrier or plan.
 
 Nancy Cavey [00:19:10]:
 Now, if you're receiving your benefits, you might be surprised to learn that the disability carrier plan has the right to have you undergo a test called a functional capacity evaluation and that FCE can make or break your claim. So I want to talk about the seven mistakes that you can make during that fce. Mistake number one is assuming that you have to attend an fce. Why do I say that? Well, your disability policy or plan may not actually require you to undergo a functional capacity evaluation. And don't be surprised if they insist that you have to go when the plan or policy doesn't say anything about that. Now, if they don't have the right, you can push back, but you can expect that the carrier will then ask you to undergo a not so independent medical evaluation. So they're going to get you coming or going, if you will. Every disability policy or plan has in the policy or plan language that says they have the right to have you undergo a ime, and that's plan B.
 
 Nancy Cavey [00:20:12]:
 Now, mistake two is ignoring instructions. If you ignore the evaluator's instructions about how to perform the test, you can literally screw up the results of the test. That can result in the assessor, the FCE assessor, finding that you have a higher level of functionality than in fact you really do. If you don't understand what the evaluator is asking you to do, ask them to repeat it, or better yet, have them demonstrate what it is they want you to do. Mistake number three is pushing through the pain and not effectively communicating your pain level. Now, despite the fact that your physician has addressed what they think your functional restrictions and limitations are, that generally is not always enough for the carrier to pay the benefits or to continue to pay the benefits because they're always looking for a reason to deny or terminate benefits. Now, the FCE is going to determine how long you can sit, stand, stoop, walk, bend, lift, whether you have any manipulative restrictions, whether you have the need to take breaks, and this exam should last between two and four hours. The examiner is going to extrapolate those findings to an ability to do full time work on a 40 hour basis.
 
 Nancy Cavey [00:21:29]:
 And one of the ways or games that the provider will play with you during the exam is to try to get you to admit that you can work full time or that they're going to try to push you to go beyond your tolerances and then extrapolate that into an ability to do a full time job. Now, if they push you, you should simply tell them that you will do what you're physically capable of based on your pain level and what your doctor has reported to you as your restrictions and limitations. So you don't want them to push you. If you're in pain, tell them that you're in pain and tell them your pain level. Now, pain levels can go from one or actually from zero to no pain to ten. You're dying, okay? And you're in the emergency room and you might start out with a certain level of pain and it will increase over the course of the fce. I want you to make sure that you are not exaggerating, that you're being truthful. Every person's pain level is different.
 
 Nancy Cavey [00:22:34]:
 But if you're reporting as you walk in, you're in a 9 or a 10, that's going to be considered exaggeration. So think about your pain level scales and be honest about that. Now, if you don't give full effort, the opposite can happen and that's the mistake number four, and that's not giving your best and full effort. If the doctor has assigned restrictions limitations to you, you should bring a copy of those restrictions to the FCE provider before you begin the testing so that the FCE provider doesn't violate those restrictions and limitations. Now, you do have to undergo the testing and you do have to give your best effort, but you shouldn't necessarily exceed your restrictions and limitations or be being pushed through your pain. There are validity tests that are built into the functional capacity evaluation and the FC provider can tell if you're not giving full effort. And one of the things you'll be asked to wear is a heart monitor that will monitor your heart rate. And so if you're not giving full effort, they're going to report that.
 
 Nancy Cavey [00:23:44]:
 And ultimately the carrier can say, well, you didn't give full effort and we're going to deny the claim. Now also be careful of this little trick. FCE providers may test parts of your body that are not involved in the disability claim and let them test it. So if you got a problem with your right arm, they may test your left arm, give full effort on both your right and your left arm. Got it? Okay. Now, mistake number five is questioning whether or not you should take medications before the fce. Generally, I suggest that you don't take your pain medication when you undergo the fce. Other attorneys suggest that you do so.
 
 Nancy Cavey [00:24:25]:
 There's this disagreement. There's no right or wrong answer. I would suggest that you ask your doctor what they think, but certainly you should be telling the FCE provider whether you've taken medication, how long ago you took the medication, how you feel, and make sure that they understand where you're at at your pain levels. As I've discussed, I also think that if you haven't taken your medication and you have the FCE and you have increased pain even after taking your pain medication, you want to keep a diary of that. Conversely, if you have taken the pain medication and you have increased pain after the fce, I think you should still keep a diary documenting what your increased symptoms are and any difficulty with functionality. So in either event, I think keeping a diary after the FCE can be really important, and you can supply that to the treating physician and to the disability carrier as documentation of the impact of the functional capacity evaluation on your symptoms and your ability to function. Now, mistake number six is thinking that that FCE provider is your friend. You can be assured that the disability carrier or plan's functional capacity evaluator is not your friend.
 
 Nancy Cavey [00:25:52]:
 You have to be very careful about what you say to the disability insurance carrier, the adjuster, your employer, even sometimes your doctor, and certainly your own physical therapist. But that also holds true with the functional capacity evaluator. What's crucial here is that you are being consistent with your report of symptoms and functionality. If you say that you can only sit for five minutes, and during the course of the functional capacity evaluation, during the intake, you sit for 15 or 20 minutes while they ask you questions. That's obviously inconsistent. So any inconsistency between what you say you can do, what's reported in your records and what you actually do can be the basis of a claim denial or termination. Why? Well, the FCE provider is going to write down in their report what you tell them and they will comment on any discrepancies, particularly as it impacts the results of your testing. So if you say that you can't push or pull more than 10 pounds, but there's video of you coming out of Costco pushing and pulling a cart that's stacked pool of heavy stuff like cases of water, that's not going to be consistent.
 
 Nancy Cavey [00:27:07]:
 So remember that you've got to be consistent. And mistake number seven is not videotaping the functional capacity evaluation or bringing a witness. Now, I know there's a fight about this. I always ask that the FCE be videotaped. And some will allow it, some won't. Some will say that the testing is proprietary, that video violates the testing protocol. I think that's a very weak reason on their part. But if they object, then plan B is to say, well, I want to bring a witness.
 
 Nancy Cavey [00:27:42]:
 Now they may say, well, you can't bring anybody off the street, but we'll allow you to bring a nurse consultant. And if that's the case, then you probably need to hire a nurse consultant to come in as an independent witness to watch that FCE and prepare a report. They're going to take contemporaneous notes about how it was conducted, how each specific test was conducted, how you did what you reported, what your complaints of pain were, and their observations of your effort. So you can see that you can easily make at least seven mistakes in an FCE that can result in a claim denial or termination. Let's take a break. But I want to let you know that in the next session I'm going to be talking about the seven ways that the carrier or plan is going to use the results of that FCE to deny or terminate your benefits. Got it? Let's take a break.
 
 Speaker B [00:28:36]:
 Professional with questions about your individual disability policy, you need the Disability Insurance Claim Survival Guide for for professionals. This book gives you a comprehensive understanding of your disability policy with tips and to do's that will assist you in submitting a winning disability application. This is one you don't want to miss. For the next 24 hours, we're giving away free copies of the Disability Insurance Claim Survival Guide for Professionals. Order yours today at Disability Claims for Professionals. The Com.
 
 Nancy Cavey [00:29:37]:
 Welcome back to Winning Isn't Easy. Let's talk about the seven ways that an ERISA disability carrier plan will use the results of a compulsory functional capacity evaluation to deny or terminate your benefits and how you can protect yourself. Now, if the ERISA disability Carrier plan has asked you to undergo a not so independent functional capacity evaluation, the question of course is, does the carrier have the right to even ask you to undergo that? If your policy or plan requires you to undergo the fce, you have to do that. The FCE is going to be performed by an occupational therapist, a physical therapist, maybe even a doctor. And the purpose of this is to determine, notwithstanding what your doctor said, what your restrictions and limitations are. The game here, particularly at the any occupation stage, is to prove that you can do at least a sedentary occupation on a full time basis. So there are lots of games that the FCE provider can play and that will ultimately be used by the disability carrier plan to justify a claim, denial or termination. So let's talk about these seven ways.
 
 Nancy Cavey [00:30:47]:
 The first is you refuse to attend the FCE and you're required under the terms of the policy to do so. The carrier is going to say you violated your duty to cooperate under the terms of the policy of the plan. Number two, they're going to say, well, you didn't give full effort and you violated your duty to cooperate under the terms of the policy or the plan. Number three, the FCE provider may have pushed you to do more than you can actually do and you wanted to be cooperative. The FCE provider is going to take that cooperation and turn it on its head and say you actually can do more than what your physician said you could do. So you're functioning at a higher level than what your physician opined. Now, number four is they're going to say, hey, the results of the FCE are inconsistent or consistent with the surveillance or social media. So again, we've talked about in the past, consistency is key.
 
 Nancy Cavey [00:31:44]:
 And so if the FCE is not consistent with what you reported on your activity of daily living forms or what you told your doctor, that's going to be fodder and they're going to combine that with with social media search and potentially surveillance. So they're looking at how can we argue that the results of the FCE are inconsistent and therefore our doctor's opinions about your level of functioning is more valid. Now the other game that they're going to play is that their vocational evaluator, internal vocational evaluator is going to look at the results of the FCE and conclude that the functional restrictions and limitations are consistent with your ability to do your own occupation if you're at that stage, or consistent with an inability to do any occupation if you're at that stage. The other game is to build on that. The FCE will be used by the vocational evaluator to do what's called a transferable skills analysis. They're going to analyze what skills you've learned in your past work and whether those skills could transfer to another occupation within whatever your restrictions and limitations are. So they're going to determine that. And that's crucial because at step seven, their ve is going to identify other occupations that you can allegedly perform consistent with your restrictions and limitations as documented by the fce.
 
 Nancy Cavey [00:33:03]:
 And of course that's sedentary type work if you're at any occupation. So the FCE provider will say you can function at a sedentary level. Their vocational evaluator will say, well, based on your past occupations, you have these skills that are transferable to other sedentary or to other or to sedentary work. And here they are. And by the way, these occupations earn or pay a wage such that no benefits are due. So you can see how this FCE can cascade, if you will, into a denial or termination. Got it. Well, I hope that you have enjoyed this week's episode of Winning Isn't Easy.
 
 Nancy Cavey [00:33:43]:
 Like our page, leave a review, share it with families or friends and subscribe to this podcast. Please tune in to another insightful episode of Winning Isn't Easy. Take care.