Disability and Disputed Illnesses: Navigating Claims Without Full Medical Recognition

Welcome to Season 5, Episode 28 of Winning Isn't Easy. In this episode, we'll dive into the complicated topic of "Disability and Disputed Illnesses: Navigating Claims Without Full Medical Recognition."

Some medical conditions cause symptoms so real and severe that they disrupt daily life, yet remain disputed or only partly recognized by mainstream medicine. For patients, it is not just a fight to be believed, it is also a fight to secure the disability benefits they need. With ERISA-governed Long-Term Disability insurance, the challenges are even greater. In this episode of Winning Isn’t Easy, disability law expert Nancy L. Cavey examines one of the most difficult areas of disability claims: conditions the medical community has not fully accepted. From chronic Lyme disease, fibromyalgia, and chronic fatigue syndrome to mental health diagnoses such as dissociative identity disorder, adult ADHD, and PTSD outside of combat, Nancy explains why these claims are often denied and what you can do about it. You will learn how insurers view subjective symptoms like pain, fatigue, and cognitive fog, why strong documentation and physician support matter, and the strategies that can help prove the impact of these conditions on your ability to work. Nancy also shares a real case example that shows how persistence and preparation can turn the tide. If you are living with a condition the medical world questions but your symptoms are real, this episode will give you the tools to fight for the benefits you deserve. Winning is not easy, but with the right strategy, it is possible.

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

One - Disputed Physical Conditions

Two - Disputed Mental Conditions

Three - Multiple Chemical Sensitivity (MCS)

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/


Need Help Today?:

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 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've got to tell you this, and now that I've told you that it's not legal advice, you Nothing will prevent me from giving you an easy to understand overview of the disability insurance world, the games that disability carriers and plans play, and what you need to know to get the disability benefits you deserve. So off we go now. Many people live with conditions that cause real and sometimes severe symptoms, yet they're not fully recognized by mainstream medicine. These disputed or controversial diagnosis can make getting your long term disability benefits a complicated and frustrating process.
 
 Nancy Cavey [00:01:00]:
 Unlike clear cut illnesses with standardized testing or imaging, these conditions often rely on subjective reports of pain, fatigue or cognitive difficulties that disability insurance carriers and plans view skeptically. This episode is going to explore both physical and mental conditions that are going to fall into this category. I'm going to look at how these illnesses present in daily life, the kinds of challenges that claimants such as yourself face when trying to prove their disability, and strategies for navigating claims when the medical community hasn't really reached a consensus on the diagnosis. So I'm going to discuss physical conditions such as chronic Lyme disease, fibromyalgia, electromagnetic hypersensitivity, chronic fatigue syndrome, and now some of these are somewhat rare, recognized, but they're still problematic. So please don't be put off by my classification of them. But we want to talk about how these medical conditions can impact work capacity and how insurers and plans will typically evaluate these claims. I'm also going to cover mental health conditions that remain controversial, including disassociative identity disorder, and I have a case involving this adult adhd, post traumatic stress disorder in non combat settings and a somatic symptom disorder. And finally, I'm going to try to connect these discussions to a real world example emphasizing the importance of documentation, physician support and understanding policy definitions of disability.
 
 Nancy Cavey [00:02:38]:
 So by the end of this episode, my goal is that you'll have a clear picture of how to approach long term disability claims for conditions that can be medically disputed or challenged regarding the existence, diagnosis, restrictions and limitations. All the elements that go into a disability claim because they're medically disputed by the disability carrier or plan, including their liar for hire physicians, but they are really no less real to the individuals experiencing them. So we want to balance this episode so that we can learn how disability carriers and plans view these claims and hopefully give you a guideline to getting the benefits you deserve. So let's get going. First, I'm going to talk about the physical conditions. Secondly, I'm going to talk about mental conditions. And three, in this real life case, I'm going to talk about multiple chemical sensitivity and how disability carriers play games, but the games that they play are the same games that they play in every type of disability claim. Got it? Let's take a break before we get started, have you been robbed of your.
 
 Speaker B [00:03:53]:
 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 [00:04:26]:
 Welcome back to Winning isn't Easy. Let's talk about physical conditions that fall into this medically disputed range of territory. Okay, now these illnesses are genuinely debilitating. And while that's the case, proving that they meet the definition of disability under a long term disability policy or plan can be challenging. And we always want to start, quite frankly with a disability insurance policy or plan and see what the language is for for the definition of disability. And we want to understand what's the nature of proof that's required. Do they require objective proof of the diagnosis of the restrictions and limitations? And what other objective medical criteria does this policy or plan require? And I will tell you there are sometimes in these objective policy requirements a laundry list of studies that they want to see to prove the actual diagnosis or the severity of the restrictions and limitations. Let's start out with chronic Lyme disease.
 
 Nancy Cavey [00:05:35]:
 Now it's reported by some patients to cause persistent fatigue, joint pain and neurological symptoms long after treatment for a Lyme infection. Now the controversy lies in the fact that most mainstream physicians do not always recognize an ongoing infection and and they don't recognize an ongoing infection as the cause of lingering symptoms. What I've seen is that they may diagnose post treatment Lyme disease syndrome, and that doesn't really have a universally accepted definition or necessarily accepted criteria for the diagnosis. And for long term disability purposes, this distinction can be critical. Policies will typically require a medically recognized condition or injury, and without clear laboratory evidence of an ongoing infection, insurers may deny claims arguing that you don't have a sickness under the terms of the policy. Now to succeed, we often will rely on detailed symptom logs, physician statements describing functional limitations, and any objective testing that can support the Claim such as imaging or lab work showing not only an infection but secondary complications from the infection. And, and it can be the post infection manifestation of symptoms that will have the objective basis of the diagnosis and the restrictions and limitations. And that's where we are generally concentrating our attention.
 
 Nancy Cavey [00:07:07]:
 Well, how about fibromyalgia? It's characterized by widespread pain, fatigue, sleep disturbances and cognitive challenges. It's widely recognized, but it still can remain controversial because, because it lacks a definitive diagnostic test, physicians will rely on symptom patterns, tender point examinations and the exclusion of other conditions. Now, while filing a long term disability claim sounds easy for fibromyalgia, what really becomes important are several things. One is there is no diagnostic test, if you will. It's a diagnosis by exclusion. And courts understand that there may not be objective testing for these types of diseases. But where courts go off is you have to demonstrate the severity of the symptoms and how those symptoms affect work. And they want to see objective evidence of the restrictions and limitations.
 
 Nancy Cavey [00:08:07]:
 So what do we do? Well, we have detailed medical documentation, we often get functional capacity evaluations, we may get CPET examinations to document the fatigue. And we want to combine that with letters and affidavits from the treating physicians, family members and the client documenting their day to day difficulties in, you know, just doing things around the house. And then we want to tie it all together with a vocational rehabilitation counselor's opinion to connect the dots. So in this particular case it's not so much the quote, unquote diagnosis that's the issue. It's documenting the extent, nature, the intensity, severity, if you will, of the restrictions and limitations. Electronic I'm sorry, electromagnetic hypersensitivity ehs. Now it involves symptoms like headaches, fatigue and dizziness and it's attributed to electromagnetic field exposure. Scientific support for this condition is extremely limited.
 
 Nancy Cavey [00:09:12]:
 Most medical organizations don't recognize it. And I will tell you for disability insurance claims, the challenge is proving that one, you have the symptoms and two, that those symptoms have an organic basis and three, that those symptoms prevent you from performing the material and substantial duties of your occupation. One of the ways that we try to address this is environmental testing, physician reports documenting symptoms and, and detailed logs of symptom severity. I will tell you, however, that disability carriers or plans really don't like these claims. And in the absence of recognized diagnostic criteria, they will really try to classify this as either it is not physically disabling or that it's actually a psychological claim because benefits are limited to just two years. These are difficult cases to prove. And again we're looking, looking at objective medical testing. If there is any objective physical findings, we are looking for any kind of robust medical evidence that documents the nature of the disabling condition, its restrictions and limitations, and then connecting those symptoms, if you will, and functional limitations to an inability to do your own or any occupation.
 
 Nancy Cavey [00:10:34]:
 Chronic fatigue syndrome, cfsme. And this will involve severe unexplained fatigue lasting six months or longer, alongside with muscle pain, cognitive impairment, and sleep disturbances. This is more widely accepted. It's accepted like fibromyalgia is, and it still, though, has its own set of challenges. The disability carrier plan is again looking for objective evidence of the diagnosis and objective evidence of fatigue and cognitive limitations that prevent job performance. So in these types of cases, we're looking at the nature of the symptoms, we're looking at the physical exam findings, we're looking at the longitudinal history of symptoms, we're looking at functional capacity evaluations, CPET exams, We're looking to put the medical evidence together. And quite frankly, it's, it is really helpful if you are seeing a CFS ME specialist, and there are centers around the United States, several here in Florida, who are well known and well recognized. Getting treatment by a facility like this can also make a difference in how the disability carrier or plan evaluates the claim.
 
 Nancy Cavey [00:11:58]:
 Again, you're going to have neurocognitive testing that can be a whipsaw, because if the disability policy or plan has a psychological, mental nervous limitation, you have to be careful. There are two flavors of the mental nervous policy limitation, and the more difficult one is the policy provision that says disability benefits are limited to just two years if your disability is caused or contributed to by psychological issues. And disability carriers in these types of cases want to pin a lot of the inability to work on depression or anxiety. When you have the neurocognitive testing, the neuropsychologist is going to be making differential diagnosis. They'll be testing you, they'll be looking for the cognitive impairment, but they're also going to be addressing the question of depression and its impact on the test results and your restrictions and limitations. So we have to be careful in these cases. And because we really don't want the depression to be, quote, unquote, contributing to the disability, we want to tease out the impacts of the impairment in terms of fatigue on your cognition. And again, we potentially want to pair that with a CPET exam that will document your functional exercise activity intolerance.
 
 Nancy Cavey [00:13:25]:
 Obviously, we want to try to tie this all together with some good hard opinions of your Physicians. Well, let's talk about disputed physical conditions and long term disability. For all these conditions that I've mentioned and some I haven't mentioned, I think there are really two key provisions in the policy that you need to be concerned about. The first is proving the existence of a medically accepted sickness or illness. Again, as those terms are defined by your policy or plan, we want to demonstrate the objective basis for your disability as that term is defined by the policy of the plan, by showing that you have symptoms that objectively and materially limit your ability to perform the material and substantial duties or the essential duties of your occupation. Now, even if the diagnosis is disputed, detailed documentation, symptom tracking and physician support can make all the difference because courts want to see in these instances an objective basis for the restrictions and limitations that impact your ability to do the material and substantial or essential duties of your occupation. It's this objective basis of the restrictions and limitations that really is key, notwithstanding whether there is a objective basis, if you will, for the diagnosis or even testing that will establish the diagnosis. Got it.
 
 Nancy Cavey [00:14:57]:
 Let's take a break. Welcome back to Winning Isn't Easy. Lets talk about mental health disorders that remain medically disputed or controversial and their impact on your ERISA disability insurance claim. The first condition is Dissociative Identity Disorder DID and it involves the presence of two or more identity states with gaps in memory. I actually represent a a policyholder in both her disability and Social Security disability claim and there are seven alt personalities and we deal with each one of these personalities. Unfortunately, the Social Security judge denied her claim notwithstanding the presence of those alts during the course of the hearing. We took that up to the appeals Council. The judge has been reversed and we're going to have another hearing.
 
 Nancy Cavey [00:16:04]:
 And at the hearing I am sure that the alts are going to be present. Now for long term disability purposes, I find that the carriers can challenge both the diagnosis and its impact on occupational functioning. These cases rely on comprehensive and significant psychiatric evaluations, therapy notes and detailed accounts about how the DID episodes interfere with the job responsibilities. And in the case I'm referring to, my client worked in the insurance industry and she had difficulty focusing, managing, dealing with deadlines, interacting with colleagues because the alts would come out at all different points depending on how stressful her work would be. And you can imagine that that just threw the employer for a loop and ultimately she lost her job. But these symptoms can materially impair the work performance and demonstrating that is absolutely critical. There's also adult adhd. It's somewhat Controversial symptoms can include distractibility, inattention and difficulty with organization.
 
 Nancy Cavey [00:17:14]:
 In a long term disability case, the insurers are often looking for objective testing, workplace accommodation and documentation of functional impairment. And that functional impairment really comes in the form of an impact on the ability to perform the essential duties rather than creating an inconvenience. From a Social Security standpoint, I will tell you that you're not going to win an ADHD Social Security claim if that's the only issue. Social Security does not take it seriously. And quite frankly, I don't think disability insurance carriers take it seriously either. It's the combination normally of other medical problems that will win the claim, not the adhd. Well, how about post traumatic stress disorder in non combat settings? It's well recognized in combat settings. It can be disputed when it arises from workplace trauma.
 
 Nancy Cavey [00:18:07]:
 Symptoms can include hypervigilance, flashbacks and difficulty sleeping. Now, when I have these kinds of cases in the context of a long term disability case, what we normally will see is post traumatic stress disorder secondary to workplace harassment, sexual discrimination or other issues in the workplace. And often disability carriers try to paint this as an employment dispute, not a psychological dispute, when in fact they can be both. It's really important to have therapy notes, psychiatric evaluations and real world examples of work impairment so, such as the inability to attend meetings, meet deadlines, maintain concentration. And we also want to address triggers. Being in the workplace, being with a certain employee, being exposed to certain individuals that they may have to deal with, particularly in a sales setting. Those are things that need to be documented. What is the trigger? Why does it trigger? What does it trigger? How long does this episode last when triggered? How does it impact the person's ability to function? So you have to establish the triggers and the connection, what the trigger results in.
 
 Nancy Cavey [00:19:24]:
 And the connection between the trauma and the functional impairment. Again, that needs to be documented significantly by medical documentation. And we try to get narrative reports from the treating psychiatrist or psychologist documenting the extent and nature of the post traumatic stress disorder triggers, how those triggers cause symptoms and impact functionality, and then tie it together on an objective basis. And then there's a somatic symptom disorder which involves persistent physical complaints with no clear medical explanation. Patients and policyholders can experience excessive thoughts, feelings and behaviors related to the symptoms. I will tell you that disability carriers and plans will scrutinize these claims. The scrutiny is just amazing. They question whether the symptoms are genuine or severe enough to prevent work.
 
 Nancy Cavey [00:20:17]:
 And as with mental health claims, they want documentation from treating physicians, functional assessments and real world examples of limitations that can substantiate the disability claim. I promise you that their liar for hire doctors will say that this does not rise to the level of causing significant restrictions and limitations in the workplace. Yes, you might have these persistent physical complaints, but they're not real. They're all psychological and benefits potentially are limited to just two years. Or if there's a subjective medical condition limitation in the policy, they will argue that because there's no organic physical issue, this is all subjective and alternatively, benefits are limited to just two years. If we can't apply the mental nervous policy limitation. These are difficult cases to win and require extensive documentation and proof. So for disputed mental conditions and long term disability, I think you need to understand that they are focused less on whether the diagnosis is universally accepted and more on whether those symptoms materially impair the person's ability to perform the material and substantial duties of their occupation or essential duties.
 
 Nancy Cavey [00:21:31]:
 It is really crucial that we have detailed documentation of the functional limitations, an objective basis for those functional limitations, therapy records that are replete with really good history of the symptoms and functionality, and psychiatric assessment with the support of a psychiatrist. It's just essential for navigating these kinds of claims with disputed diagnoses. Got it. Let's take a break.
 
 Speaker B [00:21:58]:
 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 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@disabilityclaimsforprofessionals.com.
 
 Nancy Cavey [00:22:47]:
 Multiple chemical sensitivities and your rights to long term disability benefits. I think multiple chemical sensitivity cases tie together our theme for today's podcast and I'm going to talk about how the lack of diagnosis and ability to work in other medical facilities doomed an urgent care physician's claim for unum disability benefits based on multiple chemical sensitivity. So let's take this apart. The first thing is that a disability policyholder or plan beneficiary has the burden to prove that they are disabled as that term is defined by the terms of the policy of the plan. And that can be particularly difficult in multiple chemical sensitivity claims and claims where the medical condition might be disputed or not generally accepted in the medical community. What is multiple chemical sensitivity? It's unrecognized, it's controversial. It's characterized by chronic symptoms Attributed to exposure to a low level of commonly used chemicals. The symptoms are often vague, nonspecific, including fatigue, headaches, nauseousness, and dizziness.
 
 Nancy Cavey [00:23:55]:
 Now, there are several theories that attempt to explain the cause, Ranging from allergic reactions to neurobiological sensitization. I am an individual who is highly sensitive to, to perfumes, colognes, laundry detergents, other things. I actually have an anaphylactic reaction and sometimes have to go to an emergency room. It's so bad that if I have to do live events like do a deposition, be in person for mediations, we send notices to the court and to the other parties and the court reporter saying, don't wear cologne, don't wear perfume, Be careful about how you've washed your clothes, because I will lose my voice and it's game over. I mean, I can't talk, I can't breathe, and it lasts for at least eight hours. So I get what this is about, But I obviously have objective testing that establishes the basis of my reaction. But let's talk about you. What are the typical disability policy terms in a MCS claim? Now, most long term disability policies define disability as the inability to perform the material and substantial duties of the regular occupation because of sickness and injury.
 
 Nancy Cavey [00:25:13]:
 There are two critical elements in this definition. Material and substantial duties and the existence of a sickness. Disability carriers are typically going to begin their evaluation and determining whether you have a recognized sickness. And that's often defined as an illness or disease, but it may not be in your disability policy or plan. Now, for MCS cases, this is where you face a challenge, because many insurance companies or plans will question the legitimacy of the diagnosis itself. So they will say you don't have mcs. And that can be difficult to prove because there's no objective basis for many reactions to workplace exposures, whether it's cleaning agents, fragrances, chemical irritants, sanitizers, pesticides. Many physicians don't recognize mcs, and insurance companies often have position statements disputing the condition.
 
 Nancy Cavey [00:26:09]:
 And what they will also dispute is the inability to perform occupational duties. So even if you establish symptoms, the insurance company or the plan is going to scrutinize your medical records to determine whether you can perform the materially and substantial duties of your occupation. Now, what they're going to argue is that you could work in a different environment without chemical exposures, particularly if the policy defines occupation as it's normally performed in the national economy rather than a specific location. And that would be the case if I were to file a disability claim because I can Work in my office or in my home in a controlled environment and attend these events generally by zoom. So I'm not exposed to anything. So how does this work? Let me tell you the story of Dr. McFarland. It's McFarland versus Unum Life.
 
 Nancy Cavey [00:26:58]:
 And McFarland was an urgent care physician who had specific restriction reactions rather at one facility, but he was able to work at others. He didn't have a clear diagnosis and with evidence showing that he could perform his job in alternative environments, Unum denied his claim. So what did the court do? Well, the court said, look, we don't see a diagnosis and we don't really see an objective basis for the restrictions and limitations. And we are absolutely confounded by the ability to work in other settings, but not in this particular facility. And in view of that, we think that you're not disabled because if you worked in all these other facilities, you wouldn't have these symptoms. Okay, that's too bad for the doctor. But let's talk about the takeaways from these types of claims. Navigating claims for MCS or any disputed illness requires detailed medical documentation, hopefully of a diagnosis, detailed medical documentation of restrictions and limitations, including testing functional capacity evaluations, CPET exams, any objective basis that can establish the intensity, duration, frequency and nature of the symptoms and their impact on your ability to do your own randy occupation.
 
 Nancy Cavey [00:28:23]:
 That of course requires a vocational opinion because at the end of the day, while a disputed diagnosis can add complexity, presenting a thorough and complete record, an objective basis for the restrictions and limitations and the occupational impact can maximize the chance that your benefits are awarded. But you've heard me go through the laundry list of things that need to be proven. These are not the kind of cases that should be handled on your own or handled by someone who is not an expert in ERISA disability or understands these particular types of conditions. It requires a thorough review of the policy and plan. It requires a thorough review of the medical records. It requires a strategic approach to how you are going to approve either an objective basis of the diagnosis and or an objective basis of the restrictions limitations. It's going to be dealing with your physicians and having conferences with them and getting hopefully letters of support explaining why you have the diagnosis or why you have the restrictions, limitations. It's going to require a vocational report to try to tie it all together.
 
 Nancy Cavey [00:29:37]:
 It's going to require statements from you, family, friends, colleagues. It's a whole package. It's just not I'm going to file the claim and they're going to pay benefits that doesn't happen in these types of cases. Got it. Well, thank you for tuning into this week's episode of Winning Isn't Easy. If you found this episode helpful, please take a moment to like our page, leave a review, and share it with your family and friends. Join us next week for another insightful episode of Winning Isn't Easy. Thanks for listening.