Disability Claims: Your Questions About the Medical Side, Answered

Welcome to Season 5, Episode 32 of Winning Isn't Easy. In this episode, we'll dive into the complicated topic of "Disability Claims: Your Questions About the Medical Side, Answered."

Most people assume proving disability is as simple as saying, “I can’t work.” But in ERISA claims, the medical side is where cases are often won - or lost. A diagnosis or doctor’s note isn’t enough. Carriers want detailed, consistent proof showing exactly how your conditions limit your ability to function. In this episode of Winning Isn’t Easy, we’re answering your medical questions about disability claims - and breaking down the traps insurers use to deny benefits. What happens when multiple conditions - like back pain, fatigue, and migraines - keep you from working, but insurers minimize their combined effect? How do mental health caps and exclusions for “subjective” conditions like fibromyalgia change your claim? And what are insurers really looking for in your medical records? Disability law expert Nancy L. Cavey explains how to use residual functional capacity forms to your advantage, avoid policy pitfalls, and make sure your records tell the full story. We’ll also tackle listener-submitted medical questions with practical steps you can use right now. If you’ve worried about whether your documentation is strong enough or struggled to show how your conditions prevent you from working, this episode will give you the tools - and confidence - to protect your benefits. Winning isn’t easy, but understanding the medical side puts you in control.

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

One - Multiple Disabilities and Residual Functional Capacity

Two - Policy Limitations – Mental Health, Subjective Conditions, and Benefit Amounts

Three - What Insurers Look for in Your Medical Records and Functional Capacity

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 Winning Isn't Easy. Before we get started, I have to give you a legal disclaimer. This podcast isn't legal advice. The Florida Bar Associates says. I've got to tell you that now that I've done that, nothing will ever prevent me from giving you an easy to understand overview of the disability insurance world, the games that carriers play, and what you need to know to get the benefits you deserve. So off we go. Now, today I'm going to dive into a part of an ERISA disability claim that will make or break your case.
 
 Nancy Cavey [00:00:46]:
 The Medical side When most people think about proving disability, they picture telling the disability insurance company or plan, I can't work because of my condition. And and they may assume that a diagnosis or a note from the doctor saying that they can't work is enough. But the reality is far more complicated. Disability carriers just don't want to see that you are sick, ill or injured. They want detailed, consistent medical proof that explains exactly what your condition is, the objective diagnosis of that condition, and the objective basis for any restrictions and limitations that that would impact your ability to do your own or any occupation. And here's where it gets even trickier. Very few people are disabled as a result of just one medical condition. More often than not, it's a combination of problems like back pain, migraines, heart disease, fatigue, and that can take any one of those can take you out of the workforce.
 
 Nancy Cavey [00:01:45]:
 But sometimes it's just the combination of all of those that will leave you unable to work and claiming disability. But if you don't capture the full scope of your medical issues, you risk leaving the insurance carrier or plan room to deny your claim. Now on top of that, each policy has its own set of traps. Some policies or plans will limit how medical conditions such as mental nervous conditions are evaluated. And there are other conditions clauses called subjective medical condition clauses that will limit the payment of benefits to just two years for conditions like five fibromyalgia, headaches, medical conditions that are involving pain or spasm. These clauses are incredibly broad and are used as a weapon by the disability insurance carrier or plan to limit the payment of your benefits to just two years. So you can see that it is really important that you understand the terms of the disability policy. So one you understand what it is you need to prove objectively, two that you understand if there are any policy limitations for mental nervous conditions or subjective conditions.
 
 Nancy Cavey [00:02:59]:
 And three you understand what it is you need to prove from a medical standpoint to get the benefits you deserve. So we're going to talk about three things. One is what it means to prove being disabled when you have multiple conditions and how residual functional capacity forms can be used to your advantage. Number two, I'm going to break down policy limitations from mental health caps to subjective condition limitations. And finally, we're going to dig into what insurers or plans are really looking for when they are combing through your medical records and how you can make sure that the documentation in your medical records tells the full story. So by the end, the goal is for you to understand why the medical side of your claim is a about more than just diagnosis. It's about evidence, strategy and consistency. And you'll know what steps you can take to strengthen your case and protect your benefits.
 
 Nancy Cavey [00:03:52]:
 So today I'm going to talk about three things. 1. Multiple disabilities and residual functional capacity. 2. Policy limitations, mental health and subjective conditions. 3. What insurers are looking for in your medical records and your functional capacity. Got it.
 
 Nancy Cavey [00:04:09]:
 Let's take a break for a moment. Before we jump in.
 
 Speaker B [00:04:12]:
 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 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 [00:04:47]:
 Welcome back to Winning Isn't Easy, Multiple Disabilities and Residual Functional Capacity and your ERISA disability Claim. A common question I get is can I get long term disability benefits if I have more than one medical condition? And the reality is that many people just don't stop working because of a single health issue. Instead, it's the combination of medical problems that make it impossible for them to keep up with their occupation. So maybe you have heart disease and chronic back pain. Maybe your fibromyalgia overlaps with migraines or fatigue. Each condition alone may not disable you, but when you put them all together, they can prevent you from doing your own or any occupation. Unfortunately, many people don't think about all their medical conditions when filing for disability. They might focus on the back problems but overlook the heart condition.
 
 Nancy Cavey [00:05:37]:
 Or they may claim fibromyalgia. But they don't mention the anxiety, depression, or irritable bowel syndrome symptoms that come along with it and that can ultimately weaken your case or potentially limit the amount of benefits you're eligible for. The truth is, you need to identify all the medical problems that contribute to your disability, both individually and in combination. Now here's where the policy or plan matters. Some long term disability policies or plans say, look, you can only disable from one medical condition at a time, others don't specify and they will allow multiple conditions to be considered together. Now, most disability carriers or plans, at least during the own occupation stage, is going to combine the effects of all of your conditions and consider that. However, I've found that things get a little bit trickier when the definition of disability shifts to any occupation. And that's when the insurance companies or plans often start picking apart whether your limitations are physical, whether they're mental, whether they fall under subjective category limitations, whether they fall under mental nervous policy limitations, whether in fact you are disabled on an objective basis based on the the physical exam findings and diagnostic studies.
 
 Nancy Cavey [00:06:59]:
 So the, the cherry picking of medical conditions really starts at the, sorry, any occupation stage. So how can you prove your case when you have multiple medical conditions? Well, I will tell you that I have a specific strategy and that strategy starts with the attending physician statement forms that the disability carrier has your doctor fill out. Now when you look at them, you'll see that they're pretty darn generic and most of the time they're not even actually relevant to the medical condition or conditions that are disabling you. I'm also a Social Security disability attorney and I incorporate Social Security disability residual functional capacity forms into my ERISA and individual disability long term claims. So I'm often asked, well, why is this so important and what's residual functional capacity? Residual functional capacity is what you can still do despite your health issues. So your residual functional capacity RFC may describe how long you can sit, stand or walk, whether you can bend, stoop or lift, if you have trouble using your hands, if you have trouble sitting, whether you need frequent breaks, how long you'd be off task, how often you would miss work, and any other factors that are relevant to your physical, cognitive or psychological abilities as a result of your disability. Now why is that important? Well, the disability carrier plan is going to compare your residual functional capacity form against the essential duties of your occupation. If your restrictions prevent you from performing the material and substantial duties of your occupation, you might meet the definition of disability.
 
 Nancy Cavey [00:08:47]:
 You need to understand that there is no uniform definition of own occupation. So that's why you've got to get your policy or plan out. It might be an inability to do one or more of the material and substantial duties of your occupation. It might be the inability to do the material and substantial duties of your occupation. It might be the inability to do your occupation as described in The Dictionary of Occupational Titles need to understand what that definition of own occupation is so that you can make sure that your residual functional capacity forms and the history you're giving your doctor matches up with the problems that you would be having and would prevent you from doing your own occupation duties as that's defined by the policy or plan. Now guess what? The definition in a disability policy or plan will normally change after two years and the standard becomes an inability to do any occupation. And quite frankly, that can include a consideration of your education and your prior work history and the skills you've learned. Rarely, if ever does it take into consideration your age in English.
 
 Nancy Cavey [00:10:04]:
 What an any occupation job is is basically a sedentary job, one in which you are sit limited to lifting of £10 and you are using bilateral manual dexterity, in other words your hands to meet the pace and production requirements and potentially the occupy the wage requirements of your policy or plan. Now here's the problem. Most doctors aren't trained to provide this kind of detail. They will fill out the APS forms. But as I said, I don't find that these forms often capture the full scope of the restrictions and limitations. Social Security Disability attorneys have developed over 70 different residual functional capacity forms tailored to specific conditions. They, in my view, ask the right question. And so I'm always asking the doctor to complete the APS form and the residual functional capacity form.
 
 Nancy Cavey [00:10:58]:
 I think that that is powerful evidence of a person's inability to do their own or any occupation. But that's not the only factor here. Consistency is key. Your residual functional capacity forms is completed by your doctor have to line up with your medical records. So if your doctor's notes don't document your symptoms and limitations, the disability insurance carrier plan's doctors will dismiss or even disagree with your physician's opinion about your functionality abilities, your residual functional capacity. So you can see that it takes teamwork between you and your physician to get this right. You've got to understand what the definition is of occupation. You need to make sure you're giving your doctor a really good interval history of your symptoms and how the symptoms would impact your ability to function not only at home and at work.
 
 Nancy Cavey [00:11:52]:
 And that description needs to be addressed, or addressing, if you will, the material and substantial duties of your occupation, if that's the definition, or the inability to do an essential material and substantial duty. So you want to tailor your history to that definition and you want to make sure that your physician understands the material and substantial duties, if that's the definition of occupation. So that when you're sitting down with them asking you to fill out the form. They understand what in fact the applicable definition of occupation is and disability. In other words, you don't want the doctor to fill out a form that ultimately at the end of the day says you can do your own occupation, even though it may not say that distinctly. But the way they fill out the form with the restrictions and limitations will lead the carrier plan's medical doctors to the conclusion that you can do your own occupation. And the same holds true when we get to the any occupation stage. It takes teamwork.
 
 Nancy Cavey [00:12:57]:
 Got it. Let's take a break. Welcome back to Winning isn't Easy. Let's talk about policy limitations, mental health limitations and subjective condition limitations and how that can impact your benefit amounts. Now, even with strong medical evidence, policy limitations can impact your claim. And I'm going to start with mental health. Many disability policies or plans have mental nervous policy or plan limitations. There are two versions.
 
 Nancy Cavey [00:13:35]:
 The first says that if your disability is caused by mental health condition, benefits are limited to just two years. The second and more restrictive one is the one I call the Monty Python standard of mental nervous disability claims. It's much more restrictive and what it says is look, if the disability is caused and this is the key or contributed to regardless of how small that wafer thin contribution, if there's that contribution by a mental health condition, benefits are limited to just two years and that distinction is huge. So under the second type, even if your disabling condition is primarily physical, if depression, anxiety or another mental health issues contributes, regardless of how small, to your inability to work, your benefits end after two years. Now there's another policy trap and that's called the subjective medical condition clause. Not all disability policies or plans will have this, but that's one of the things that I'm looking for when I'm doing a policy or plan review. This nasty subjective medical condition clause allows insurers to exclude conditions they argue can't be proven by objective evidence. And in this subjective medical condition limitation, there will be a laundry list of conditions that they say we consider to be subjective.
 
 Nancy Cavey [00:14:53]:
 And if we see these benefits are limited to just two years if that in fact is the cause of your disability. So examples can include migraines, fibromyalgia, chronic pain, muscle spasm without nerve involvement. As I said, there's just a laundry list. If your plan has these limitations, these conditions may not count when your claim shifts to any occupation stage. And then they'll start cherry picking. Well, they'll say this one, you got Migraines, that's out. You got fibromyalgia, that's out. You have a herniated disc, but you've had surgery.
 
 Nancy Cavey [00:15:33]:
 And there's no evidence based on the post operative scans or EMG that you have any nerve involvement, that condition is out, et cetera, et cetera, et cetera. So you can see that this can impact the value of your claim because benefits are limited to just two years, if any one of those policy limitations or planning limitations are applicable. Now, I also get asked, if I have more than one disabling condition, does that benefit amount increase? Now I know that some in our audience are veterans and they may be collecting VA benefits. And long term disability is not like the VA system where each condition adds to the compensation. In other words, they're given a rating and you can add the ratings together. Ultimately, if you have 100% disability, you're going to be paid 100% benefits. That's not how it works here. There is no impairment rating schedule and you can't stack multiple disabling conditions to get more money.
 
 Nancy Cavey [00:16:38]:
 Again, in the VA system you can stack and get more money in the context of a long term disability case. Your monthly benefit is fixed based on the percentage of the income benefits that you selected when you bought your policy or enrolled in the plan. So in other words, it might be that you've bought a policy that will pay 60% of your base wage. That's what you're going to get unless you bought what's called a buy up provision in your policy that allows you to increase the amount of your benefits at certain regular intervals. Of course you've got to pay an additional premium. Now the one that you might see is a cost of living adjustment, a COLA, much like the COLAs that you've heard about in Social Security cases. But not every disability policy or plan has these provisions. Now another common question I get is, look, if my medical condition gets worse, do my benefits go up? And again, the answer is no, Your benefits amount is going to stay the same regardless of whether your health deteriorates or whether you develop new conditions.
 
 Nancy Cavey [00:17:42]:
 Now, worsening health might help you prove that you remain disabled, but it's not going to increase your monthly check. So that's why it's really important that before you stop working and apply for benefits, you understand the policy or plan language. What is the definition of disability? What's the definition of occupation? How long are my any occupation benefits? Is there an elimination period, which is a period that you have to be disabled but you aren't going to get benefits? Do I have long term disability benefits? To what point in time based on the policies at the age 65, age 67? Are there limitations in what I can get based on mental health policy limitations? Who are subjective medical condition limitations and are there offsets? An offset such as the receipt of Social Security disability benefits? You need to understand all of this before you stop work and apply for benefits. Because in my view, the strategy starts just before you stop work and apply for benefits. It's a little hard to get bad news after you've applied for benefits and learned that your benefits may be limited to just two years because you have fibromyalgia. And obviously you want to have done some financial planning before you stop working apply for benefits knowing that your benefits would stop in just two years. Got it. Let's take a break.
 
 Speaker B [00:19:12]:
 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@disabilityclaimsforprofessionals.com.
 
 Nancy Cavey [00:20:02]:
 Welcome back to Winning Isn't Easy. What are disability insurance carriers or plans looking for in your medical records in determining your functional capacity? Now let's look at how disability insurance carriers or plans evaluate your medical evidence when you file a claim. One of the first things the disability carrier plan is going to do is to request your medical records. And when they get them, they're going to review them cover to cover. Now you need to understand these days that they are using AI to do medical summaries and they're probably giving the AI certain queries about what it is they're going to be asking it to look for. In terms of your medical records. One of the things they are looking for is a long term relationship with your your doctor. Even though the Arisolol does not give a special weight to treating physicians, I find that insurers will give more weight to records from doctors you've seen consistently over time.
 
 Nancy Cavey [00:21:02]:
 Now that doesn't mean to say that they're going to defer because there is no treating physician rule in the context of an ERISA case. But regular visits show continuity of care. The second thing they're looking for is detailed documentation of your symptoms. Now, saying that you're fine at appointments can seriously damage Your claim. What's an insurance company or plan gonna do in interpreting that term? Well, they're gonna interpret it as proof of improvement. So instead, I think you should be describing your symptoms, whatever they are, be they pain, fatigue, cognitive issues in terms of how they interfere with your activity of daily living. For example, if you've got migraines, you wanna be able to go into the doctor and say, look, since I you. I've had six migraines.
 
 Nancy Cavey [00:21:52]:
 They've each lasted three days. I've been in a cool, dark room with compresses on my head, no noise, I vomit. I have. I'm nauseous, I can't eat. When the migraine ends, I feel like I've been run over by a truck. So I feel like I've got to add another day to recover from the migraine. And this is how it impacted my ability to function. I didn't eat, I couldn't cook, couldn't take care of my kids.
 
 Nancy Cavey [00:22:22]:
 So that the doctor has an understanding of the symptoms and has an understanding of the functionality. Now, there's also a flip side here. I told you that disability carriers and plans will pay attention to the physician's records, particularly if they've treated you over time. But if your doctor says the same thing over and over in your medical records, that's a problem. Because the disability carrier plan can't figure out what's going on. How can this person necessarily have the same exam findings every visit? How can the complaints be the same? How can the treatment be the same? How can there not be any change in the treatment modalities? And how come there isn't a referral to a specialist? So the same rigmarole, if you will, that you see in medical records can be a problem. Number three, they're looking for consistent treatment and compliance. Regular visits, in my view, prove ongoing disability.
 
 Nancy Cavey [00:23:25]:
 But skipping appointments, refusing treatment without explanation, or stopping care altogether is a no no that leads insurers to assume that you've recovered. Even if your doctor says that there's nothing more they can do for you, you still should have scheduled visits to document your condition, that interval, history of symptoms and functionality, your response to treatment, or the lack of response to treatment. What we're looking for here is documentation of symptoms and functionality and certainly the doctor's continued recommendation that you do certain things to maintain your functionality. They may suggest that you continue to engage in continued home exercise or to attempt to swim or to do other things. So just because the doctor isn't necessarily offering palliative care doesn't mean that you shouldn't be seeing them. In fact, what you probably should be doing is asking them to make referrals to other physicians for further evaluation and treatment. Now, that leads me to number four, specialist involvement. Carriers prefer evidence from specialists.
 
 Nancy Cavey [00:24:37]:
 So if you have Parkinson's, ms, fibromyalgia, migraines, cardiac issues, they want to see treatment notes from a specialist. They're going to carry more weight than the records from a primary care doctor or a chiropractor. So when possible, we want these specialists to complete the APS forms and those applicable residual functional capacity forms that we Social Security lawyers use. Now, beyond your records, what's going to happen is that the insurance company or plan is going to conduct their own analysis of your residual functional capacity across physical, psychiatric and cognitive domains. They're going to send your medical records to their liar for hire peer review nurse or doctor and ask questions about your physical residual functional capacity. And that is how long you can sit, stand, walk, how much you can lift, whether you need to change positions, whether you have problems with bilateral manual dexterity. And they're going to ask the doctor to come up with their own opinion about your restrictions and limitations. They will cherry pick your doctor's medical records.
 
 Nancy Cavey [00:25:44]:
 They will say that the restrictions and limitations assigned aren't supported based on your physical exam findings, the diagnostic studies, your report of your own activity, whatever it is they can find to cherry pick the records. They're also going to send as appropriate, your medical records to a psychiatrist for a determination of your psychiatric residual functional capacity. Among the things that a psychiatric RFC measures or attempts to quantify is your ability to handle stress, to adapt to change, to get along with others, to maintain focus, to handle simple, routine repetitive tasks, or to accept criticism in the workplace. And I will tell you that again, the lie for hire peer review psychiatric reviewers will cherry pick and criticize the records. They'll say something like the person's not necessarily compliant with the medical treatment or if the person really had the level of psychiatric symptoms of which they're complaining, they would be in a hospital or the treatment would be more frequent, or the medication would be different. So cherry picking is going to be seen even at the psychiatric level. It gets worse. I think when we get to the cognitive issues, cognitive residual functional capacity is your ability to concentrate, how your memory might be impacted, how your executive functioning might be affected.
 
 Nancy Cavey [00:27:15]:
 And again, they're going to use liar for hire psychologists or neuropsychologists to say, look, this person showed up at the doctor's office and had A normal mini mental status exam like that is really determinative of anything that asks questions like what day is it, what month is it, who's the president, you know, sort of stupid stuff. That mini exam in no way measures your cognitive abilities. What they're looking for again is medical records that document your psychiatric functioning or your physical functioning and how pain or psychiatric conditions might impact your cognitive functioning. If you've got PD or you have ms, you're going to have neurocognitive issues. If you've got Alzheimer's or early onset dementia, you're going to have cognitive issues. So they're going to be looking for neuropsychological testing. There is a bit of a trap here because in that testing the neuropsychologists are also going to be determining whether you have depression or anxiety that is contributing to your disability or the diagnosis. Remember, we've talked about the two year mental nervous policy limitation and if you've got one of those Monty Python mental nervous policy provisions, you can be in trouble here.
 
 Nancy Cavey [00:28:41]:
 Why is that? Well, what happens here, remember, is that in the Monty Python mental nervous policy limitation, if a psychological condition like depression contributes every so slightly to disability, benefits are limited to just two years and depression can be a factor in cognitive issues. What happens here, of course, is that the disability carrier plan is going to refer your case to their liar for hire peer review doctor who is going to second guess your cognitive impairment. Generally they'll say that you know, your complaints or the exam findings or the diagnostic studies just don't demonstrate the level of severity of your complaints, or that there's no objective basis for them, or you know, it's all psychologically induced. You can see how denials can be based on the peer reviewed doctor's analysis of your medical records. That's why I think it's critical to have your own doctors complete residual functional capacity forms and ensure that your records are fully documenting your symptoms. And without that, in my view, the disability carrier plan is controlling the narrative. Remember, if your claim is denied, you'll only have 180 days in which to take an appeal. And during that time it is really essential that you strengthen your medical evidence.
 
 Nancy Cavey [00:30:05]:
 Attack the carrier's review, attack those desire for hire peer review doctors, present your RFC clearly, get any testing that could document or corroborate your level of functioning, hopefully have your doctor endorse it or get the statement, get statements from family members, friends, maybe even co employees. All of that goes together in attacking the wrongful basis of the denial or termination of your claim. Remember, you want to be attacking the factual basis, the medical basis, the the vocational basis, and of course, the legal basis. Clearly, an ERIS attorney such as myself can coordinate with your doctors, get the necessary medical evidence, develop the necessary medical evidence, develop the necessary vocational evidence, challenge policy limitations, and build the record to overturn the denial. Remember, in an ERISA case, that appeal is the trial of your case. So once the appeal process is ended, you really can't add any new evidence. There is no trial and you don't get your day in court. In an ERISA disability case, in other words, there's no jury trial.
 
 Nancy Cavey [00:31:14]:
 Most of these cases are decided on what's called a motion for summary judgment, which are legal pleadings that the lawyers exchange. I want you to remember it takes teamwork between you, your doctors, and your legal team to secure and keep your long term disability benefits. Thanks for tuning in today. I hope you found this episode helpful. Please take a moment to like our page, leave a review, share it with your family and friends, and subscribe to this podcast. I also love to hear from our listeners. At the beginning of each episode description, you're going to find a link where you can send us your questions or comments. I might even feature them in a future episode.
 
 Nancy Cavey [00:31:53]:
 So join us next week for another insightful episode of Winning Isn't Easy. Thanks for listening.