Conditions That Might Be Subject to Term Limitations or Exclusions – Understanding Them, and Why

Welcome to Season 5, Episode 10 of Winning Isn't Easy. In this episode, we'll dive into the complicated topic of "Conditions That Might Be Subject to Term Limitations or Exclusions – Understanding Them, and Why."

Join attorney Nancy L. Cavey, a leading expert in disability claims, for an insightful discussion on medical conditions that may be subject to term limitations or exclusions. Many prospective disability applicants believe that if they have a medical condition and a doctor confirms they are disabled, they have an open-and-shut case. Unfortunately, this is often not the case - particularly when the disability is mental in nature, or when a physical disability is partially linked to a mental health condition. In today’s session, Nancy L. Cavey will explore a range of medical conditions that could be subject to these limitations or exclusions and explain why.

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

One - Drug Addiction / Substance Abuse and Your ERISA Disability Claim

Two - Alzheimer’s Disease and Your ERISA Disability Insurance Claim

Three - Gender Dysphoria and Your ERISA Disability Insurance Claim

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.


Listen to Our Sister Podcast:

We have a sister podcast - Winning Isn't Easy: Navigating Your Social Security Disability Claim. Give it a listen: https://wiessdpodcast.buzzsprout.com/


Resources Mentioned in This Episode:

LINK TO ROBBED OF YOUR PEACE OF MIND: https://mailchi.mp/caveylaw/ltd-robbed-of-your-piece-of-mind

LINK TO THE DISABILITY INSURANCE CLAIM SURVIVAL GUIDE FOR PROFESSIONALS: https://mailchi.mp/caveylaw/professionals-guide-to-ltd-benefits

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


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Need help with your Long-Term Disability or ERISA claim? Have questions? Please feel welcome to reach out to use for a FREE consultation. Just mention you listened to our podcast.

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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 [00:00:00]:
 Foreign hey, I'm Nancy Cavey, national ERISA and individual disability attorney. Welcome to this episode of Winning Isn't Easy. Before we get started, I've got to give you a legal disclaimer. This podcast isn't legal advice. The Florida Bar association says I've got to say this, and so I've said it. But I will tell you that nothing will 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. I know that securing the disability benefits you deserve is challenging enough, but many disability policies or plans have some policy limitations or exclusions that that you need to understand.
 
 Nancy Cavey [00:00:58]:
 That's crucial because while I don't support those restrictions and limitations, you've got to understand the impact of those on your benefits and the strategy that goes into play, if you will, to try to minimize the applicability or even impact of these provisions. So today I'm going to give you a few examples to give you a broad perspective on the types of conditions that disability carriers will often resist covering or or will only argue or limited to a specific period. And normally it's two years. Let's first talk about drug addiction and substance abuse and an ERISA disability claim. Next, I want to talk about an Alzheimer's disease claim and ERISA disability benefits and why a claim for Alzheimer's benefits might be limited to just two years under a mental nervous policy limitation or a subjective medical limitation. And lastly, I want to talk about gender dysphoria and an ERISA disability claim and again, why a claim for disability as a result of gender dysphoria potentially could be limited to just two years of benefits. So let's take a break before we dive into these medical conditions and understanding more about policy limitations or exclusions that can impact your ERISA disability claim.
 
 Speaker B [00:02:18]:
 Have you been robbed of your peace of mind by your disability insurance carrier? You owe it to yourself to get a copy of Robbed of your piece of 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 [00:02:41]:
 Welcome back to Winning Isn't Easy. Let's talk about drug addiction, substance abuse and your ERISA disability insurance claim. We all know that drug addiction is an epidemic. It impacts Americans of all ages, all occupations. I'm often asked, look, can I collect the risk of disability benefits if I'm disabled due to drug addiction? Now, in answering that question, we need to go to the disability policy or plan. Many disability policies plans will have limitations on how long a person can collect disability benefits for a drug addiction issue. Now, typically there are two provisions that come into play. The first is the substance abuse clause that will normally limit the payment of benefits to just two years.
 
 Nancy Cavey [00:03:30]:
 The second is a mental nervous policy limitation that can also restrict benefits to just two years if the disability is caused or contributed to by a psychiatric condition. Some disability policies or plans will categorize substance abuse as a psychiatric condition, making it subject to either the two year substance abuse limitation or the two year mental nervous policy limitation. If that specific provision is absent, I see that disability carriers or plans often argue that the substance abuse stems from an underlying psychiatric condition, thereby imposing the two year limitation. I will also tell you that many policies or plans state that losing a professional license doesn't equate to a disability. So if you're a physician or a physician's assistant, or a nurse whose license has been suspended or revoked due to drug addiction, your license status is really irrelevant to your disability claim. Let's talk about addiction to a prescription medication. Now I've represented people who have had multiple spinal surgeries or multiple surgeries for other painful conditions and unfortunately they have become addicted to to narcotics. I'm often asked, well look, can my risk of disability benefits be limited to just two years? I mean, after all, I'm disabled because of my back pain.
 
 Nancy Cavey [00:04:58]:
 But I do have this addiction issue. The answer is going to be found in that policy or plan. If your disability is due solely to your spinal condition, you might qualify for benefits beyond the standard limitation. But your doctor is really going to have to make it clear that you are disabled because of the physical manifestations of your spinal condition and pain, not because of your addiction to medication. On the other hand, if your disability stems solely from substance abuse, basically we're going to be looking at a two year limitation. If the substance abuse is linked to an underlying psychiatric condition and people will self medicate with psychiatric conditions, benefits are most likely going to be limited to just two years. The there are four common reasons that ERISA disability claims for substance abuse are denied. And I think it's important that you understand these.
 
 Nancy Cavey [00:05:50]:
 But once again we have to go back to your specific policy or plan. Common defenses can include number one, the substance abuse is classified as a pre existing condition is excluded under the terms of the policy. Number two, the substance abuse is deemed to be self inflicted due to your voluntary use or number three, the insurance company argues that you wouldn't be Disabled, if you adhered to the medication treatment regimen and that you are abusing that medication and then you're not following appropriate medical advice. Number four is that they are going to argue that you're just not disabled, period. Doesn't matter what your condition is, you're just not disabled. Now, normally what I will see is, is the argument that your addiction is the cause of your disability. Number two, you're not compliant with treatment and therefore you're violating the terms of the policy or the plan. So even if benefits were limited to, weren't limited to, rather if they were limited to just two years, there still would be an issue because you're non compliant with your medical treatment.
 
 Nancy Cavey [00:07:03]:
 Again, it goes back to what's in your medical records, what's in your prescription history, whether your doctors are of the opinion that you're using and abusing, and whether or not they believe that your disability is caused by or contributed to that substance abuse. It's a case by case, policy by policy, type of determination. But if you're facing that particular issue, I think you need to understand very well that there's potentially going to be a argument that your benefits are limited to just two years because of drug abuse or substance abuse. Got it. Let's take a break and when we come back, we're going to talk about Alzheimer's disease and what's called a subjective medical condition limitation. Got it. Welcome back to Winning isn't Easy. Alzheimer's disease, subjective medical condition limitations, and your ERISA disability insurance claim.
 
 Nancy Cavey [00:08:14]:
 I hope that you are not disabled or a loved one is disabled as a result of Alzheimer's. It is a horrible disease both cognitively and physically. There are three early signs of Alzheimer's disease. Now, it's a progressive neurological disorder that affects memory, thinking and daily functioning. And what I see in my practice is that about 80% of dementia cases are caused by Alzheimer's. When I'm looking at one of these cases and trying to help a client apply for benefits, we're looking at three early signs. The first is memory loss and cognitive decline. I find that the client or their relatives are coming in saying, look this, having frequent memory lapse, they're misplacing items, they're forgetting recently learned information.
 
 Nancy Cavey [00:09:02]:
 They're struggling with tasks requiring planning or coordination. And that's particularly true, for example, in my stockbroker or banker, accountant, financial planner type clients, where that memory loss and those mistakes become abundantly clear rather quickly. The second thing people will come in and comment on is that their loved one or they are having changes in their behavior, their personality, their mood swings, their irritability, their social withdrawal. The most gregarious and friendly person has become a recluse. And number three is difficulty with familiar tasks and spatial awareness. Again, this is difficulty performing basic routine tasks, confusion about time and place, difficulty getting from place to place, from the home to the grocery store, changes in in challenges with visual spatial relationships such as judging distances or even recognizing faces. All of those are early signs and should be well documented in a claim. But before you stop work and apply for benefits, the starting point is to obtain and review that disability insurance policy or plan to understand what the definition of occupation is of disability and the requirements for for proof.
 
 Nancy Cavey [00:10:22]:
 What I do find often is that the medical records are not documenting these kinds of symptoms to demonstrate that the person is unable to perform their own or any occupation. And as a result, I always have to recommend neurocognitive testing to establish a baseline in functioning. It might be that the person is not yet so disabled that they can't perform their occupation, but it's coming and we want to have the baseline proof. Now. The other problem that I will see is that people don't understand on the other end, what are the policy limitations and provisions that could impact the payment of benefits? And there are several that are applicable here. One is a mental nervous policy limitation that can limit benefits to just two years. And that limitation comes in two forms. One is the policy policy provision or plan provision that says, hey, if your disability is caused by a mental nervous condition, benefits are limited to just two years.
 
 Nancy Cavey [00:11:25]:
 Then there's the other one. I call it the Monty Python wafer thin contribution. If your disability is contributed to, regardless of how small, by a mental condition, then benefits are limited to just two years. I'm sure you're saying to me, but Nancy, Alzheimer's is an organic brain issue, not a psychiatric condition. True. However, in disability policies or plans, there might be language that defines Alzheimer's as a psychiatric condition. And if that's the case, I do think that there are grounds and should be grounds for challenging the applicability of that policy limitation. The other policy limitation is what's called a subjective medical condition limitation.
 
 Nancy Cavey [00:12:12]:
 Now, many of the complaints that I just enumerated involve memory, cognitive functions, decision making, sort of subjective in nature, unless there is objective neurocognitive testing documenting deficits in those areas of executive functioning. What's worse, of course, is that the progression of Alzheimer's is slow and it varies from person to person. It can make it challenging to prove the extent of the disability and and that it really isn't a subjective medical condition limitation. We do know that in the early stages of Alzheimer's there might not be an obvious physical manifestation and that can make it harder to meet not only the objective proofs that your policy or plan may require, but to get around that subjective policy limitation. Again, I think that it's really crucial that your medical history is documenting the nature of those symptoms and functionality, but that there is objectives, for example, MRIs or brain scans documenting involvement in the executive functioning area. And combine that with neurocognitive testing that can document that there is an organic cause for the cognitive problems that you are or your loved one is demonstrating. So it's comprehensive medical documentation with a great history and good testing that will document the extent and nature of not only the symptoms, but the impact on functionality. If you're facing a challenge in trying to pick the right date to become disabled as a result of Alzheimer's, you really should be consulting with an experienced ERISA disability attorney who can help you understand the terms of the policy and the plan, look at those medical records, but ultimately in advance, start thinking about how the disability carrier plan can potentially use that mental nervous policy limitation or that subjective policy limitation as a hammer to try to deny or terminate benefits.
 
 Nancy Cavey [00:14:17]:
 Got it? If you have any questions about this, please take the time to contact an experienced ERISA disability attorney. But in the meantime, let's take a break before we head into our last segment of this podcast episode.
 
 Speaker B [00:14:33]:
 Are you a professional with questions about your individual disability policy? You need the Disability Insurance Claim Survival Guide for Professionals. This book gives you a comprehensive understanding of your disability policy with tips and to dos 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 are giving away free copies of the Disability Insurance Claim Survival Guide for Professionals. Order yours today today@disabilityclaimsforprofessionals.com.
 
 Nancy Cavey [00:15:21]:
 Welcome back to Winning Isn't Easy. Gender dysphoria and your ERISA disability insurance claim. Now, look, I'm not going to get into the politics of gender dysphoria that's beyond the scope of this podcast. But having represented individuals who have gender dysphoria, I can tell you that it can significantly impact a person's ability to work, potentially qualifying them for their ERISA disability insurance benefits if they have a disability insurance policy or plan. There is no doubt, no doubt at all, that obtaining benefits for gender dysphoria can be challenging due to the bias from insurance companies, claims examiners, peer review physicians and even judges. But nonetheless, let's talk about this. There is of course, the psychological impact of gender dysphoria. There are several psychological conditions that are linked to gender dysphoria that can impact a person's ability to perform their own or any occupation.
 
 Nancy Cavey [00:16:18]:
 First, there's anxiety, the fear of public interactions due to past bullying or harassment. Number two, there are panic attacks, which are severe anxiety that leads to panic attacks, cold causing avoidance of public spaces and work environment. There's of course depression, which is feeling of isolation, loss of motivation, social withdrawal, which can all make it difficult to function at work. There's post traumatic stress disorder, trauma from harassment or violence that can lead to flashbacks, sleep disturbances, avoidance behaviors, and all of that can impact a person's work performance. There are other psychiatric conditions that can be seen, but you need to understand that regardless of what they are, there is generally an A and a risk to disability policy or plan. A mental nervous policy limitation that will impose a two year benefit limitation for disabilities caused or contributed to by psychiatric conditions such as anxiety, depression, post traumatic disorder, bipolar disorder. But that application will in part depend on the language and the policy of the plan. If the disability is caused by these psychological manifestations of gender dysphoria, benefits most likely can be limited to just two years.
 
 Nancy Cavey [00:17:38]:
 But if there are other physical manifestations or physical issues that are the basis of the disability, potentially there's a workaround, if you will, that two year mental nervous policy limitation. It's much more difficult if you have what I call the Monty Python versus version of the mental nervous policy limitation, which is where the disability is contributed to, even so slightly by any one of these psychological manifestations. I think that it is key before you stop work and apply for your benefits, that you understand what's in that policy or plan, that you understand the definition of disability occupation and the mental nervous policy limitations. There might even be a subjective medical condition limitation in that policy. Secondly, you need to understand what's in your medical records. Is there an objective basis for the diagnosis? What are your disabling symptoms both physically and psychiatrically, and how do they impact your functionality? And is there documentation of the treatment plan and your response to that treatment? Many times what I do is I supplement the physician's attending physician's statement that's used in every ERISA case with a Social Security disability mental residual functional capacity form. Now, I do that because we want to document difficulties with concentration, following instructions, interacting with others, staying on pace, completing things in a timely manner, attendance, that sort of thing. That form will get at those kinds of questions.
 
 Nancy Cavey [00:19:10]:
 When I find that the carriers attending physician statement forms just don't ask the right questions. I also want to get statements from coworkers or former employers who can further support the difficulties that they've observed with you in the workplace. Of course, if we have other disabling medical conditions, we want to add them to the basis of the claim. We want to make sure that we're covering all of the physical and psychological reasons why a person might be eligible for their ERISA short or long term disability benefits. You can see it's going to be a challenge from the very beginning. And knowing what's in your policy or plan, knowing what's in your medical records, understanding what it is you have to submit to prove your disability is the key to getting those short and long term disability benefits. Got it. Well, I thank you for tuning in to this week's episode of Winning Isn't Easy.
 
 Nancy Cavey [00:20:00]:
 If you found this episode helpful, please take a moment to like our page, leave a review, and share it with your friends and family. And please subscribe to our podcast so you'll get notification of the next episode of Winning Isn't Easy. Thanks, Sa.