Frozen, Torn, or Unstable: Proving Shoulder Disability Claims

Welcome to Season 5, Episode 36 of Winning Isn't Easy. In this episode, we'll dive into the complicated topic of "Frozen, Torn, or Unstable: Proving Shoulder Disability Claims."

Most people think that getting disability benefits for shoulder problems is as simple as showing medical proof - MRI results, surgical records, or doctor’s notes about your pain and limited motion. But when it comes to Long-Term Disability claims, that’s just the beginning. Insurance carriers often twist the facts, using your own records, treatment notes, or even your words against you to argue that you’re “better” or “should have recovered by now.” In this episode of Winning Isn’t Easy, disability law expert Nancy L. Cavey breaks down what really happens when shoulder disorders collide with the claims process. You’ll learn how the shoulder actually works, and why even a “minor” injury can make it impossible to perform the essential duties of your job. Nancy covers the most common conditions that lead to claims, from rotator cuff tears and frozen shoulder to chronic instability and dislocations, and explains how insurers use tactics like “medical improvement” arguments, surveillance, and Activities of Daily Living forms to undermine your case. You’ll also hear practical advice on how to document your symptoms, treatment progress, and job limitations so your claim tells the full story - not the version your insurance company wants to tell. If your carrier says you’ve recovered, or insists you should be able to work through the pain, this episode shows you how to push back with medical evidence, clarity, and confidence. When it comes to shoulder disabilities, understanding your body, and your rights, can make all the difference. Winning Isn’t Easy, but with the right strategy, you can keep your claim strong and your benefits protected.

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

One - Understanding Shoulder Disorders, Anatomy, and the Claims Process

Two - Rotator Cuff Disorders and Long-Term Disability

Three - Frozen Shoulder and Long-Term Disability

Four - Shoulder Instability and Dislocation in Disability Claims

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 qua

Transcript

Nancy Cavey [00:00:00]:
 Foreign hey, I'm Nancy Cavey, national resident 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 that. But. But now that I've said it, 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.
 
 Nancy Cavey [00:00:38]:
 So let's get going. Now, in today's episode, I want to focus on shoulder disorders and long term disability claims. Shoulder problems are some of the most common musculoskeletal issues in America. In fact, it's estimated that over 2 million people experience shoulder injuries or chronic pain every year. And when those conditions become severe, they can prevent you from performing the essential duties of your occupation, making disability benefits critical. But here's the problem. Disability insurance carriers and plans are always looking for a reason to deny or terminate benefits. They use tricks like claiming there's been medical improvement or mischaracterizing your treatment or arguing that you should have recovered by now.
 
 Nancy Cavey [00:01:22]:
 They'll comb your medical records, they'll send you activities of daily living forms, and they'll even call you directly. And let's that's not a friendly chat to get you to say something that can be used against you. Now, in today's episode, we're going to take a closer look at how the shoulder works, why problems with this joint can make it difficult to work, and what you need to understand before filing a disability claim. I'm going to dive into some of the most common shoulder conditions like rotator cuff tears, which I've had, frozen shoulders and an instability or dislocations. We're going to talk about the challenges that people face when insurers are placed. Plans try to deny or downplay the impact of these conditions. So let's get going. I'm going to talk about four things.
 
 Nancy Cavey [00:02:05]:
 First, some basic anatomy. Well, understanding shoulder disorders, anatomy and claims processes. We're going to be in number two, rotator cuff disorders and long term disability. Three, frozen shoulder and long term disability and four, shoulder instability and dislocations and disability claims. Now before we get started, we're going to take a quick break. Welcome back to Winning Isn't Easy. Let's talk about understanding shoulder disorders, anatomy and the claims process. The shoulder is the most mobile joint in the human body.
 
 Nancy Cavey [00:02:48]:
 It allows you to lift, to rotate, to throw, reach overhead. But that mobility comes at a cost. The joint is inherently unstable. So I want you to think with me about some basic anatomy. The shoulder joint has three bones. The humerus or the upper arm, the scapula or the shoulder blade, and the clavicle or the collarbone. Think of the joint as a shallow cereal bowl, and I want you to think of the joint as going into that cereal bowl. The top of the humerus is shaped like a ball, and it will sit inside the bowl of the scapula.
 
 Nancy Cavey [00:03:25]:
 Now, the ligaments, the tendons, and the rotator cuff muscles keep that ball centered, while the clavicle will provide support so that the arm can move freely. The shallow socket, again, the cereal bowl, is why shoulder disorders are common. The ligaments and the muscles have to maintain an extraordinary amount of work to maintain stability. And when one part of this system is damaged, whether it's the rotation rotator cuff or the capsule around the joint or the ligaments, the entire shoulder can lose strength, stability and function. Now, from a disability insurance carrier or plan standpoint, this matters because many jobs require frequent use of the arms and shoulders. Lifting boxes, typing on a computer, assisting patients, operating machinery, or even reaching overhead to stock a damaged shoulder doesn't make this type of occupation painful. Sometimes it can make it absolutely impossible. But here's the catch.
 
 Nancy Cavey [00:04:23]:
 I have found in my many years of practice that disability insurance companies and plans don't always understand this anatomy, and they often rely on narrow disability duration guidelines. Now, these guidelines, by the way, written by liar for hire peer reviewed doctors who have formed their own companies, these guidelines, they give conservative estimates of how long recovery should take after surgery or injury, and carriers will treat them as absolutes, as if every person heals the same way. When in reality, recovery is highly individualized. For example, in the case of hall versus AT&T umbrella benefit plan number three, hall had a very serious shoulder disorder, impingement arthropathy, and a labral tear. She underwent two surgeries in physical therapy, and while her range of motion improved slightly, her pain and functionality didn't. And her doctors restricted her from reaching overhead, lifting more than 15 pounds, or even flexing and extending her neck for long periods. In other words, she couldn't work. But the disability insurance carrier saw something different.
 
 Nancy Cavey [00:05:31]:
 They looked at her medical records and saw the word improvement. They noted normal MRIs, normal cervical spine examinations, and they concluded there wasn't any objective evidence to support her restrictions and denied her claim. Now, she appealed, but she failed to submit new evidence and the federal judge sided with the carrier, pointing to this lack of objective findings, her benefits were gone. So let's talk about the lessons that could and should have been learned in this particular case. So let's go back to the anatomy of the shoulder. Yes, there was normal MRIs, normal spine examinations, but I didn't see in this particular case whether there were any X rays taken to address the status of the bones. In other words, was there still impingement? Was there still arthropathy? Was the labral tear really healed? There is no indication that she had a MRI arthrogram of the shoulder which would also have helped delineate any continuing problems objectively within the terms within the shoulder, based on the shoulder's anatomy. Secondly, her doctor should have documented her restrictions in detail.
 
 Nancy Cavey [00:06:52]:
 In terms of the functionality, was there a limited range of motion? Was there difficulty moving her arm in front of her over her head, to the side, behind her arm? Did she have problems with weakness when that arm was extended or kept in a static position? Now, one of the ways of course, to get to that would have been a functional capacity evaluation, which is an objective measure that can be used to determine the functionality of the shoulder. Or she could have potentially gotten an IME by a shoulder specialist to address these functional restrictions and limitations and the objective basis for the same. And of course she could have gotten a personal statement consistent with her medical evidence about her difficulty functioning. Maybe even a video would have been appropriate. And lastly, of course an experienced ERISA disability attorney would have helped her make the legal and medical case that she was disabled as those that term was defined by her policy or plan, but put together the winning medical evidence to rebut all of the reasons that the disability carrier created to deny this claim. Otherwise, they're going to play this medical improvement game and you're going to lose. So now that we set the stage for some of these games, we understand some basic anatomy, we understand some of the games that carriers play. Let's move into the first major shoulder disorder we that we see in disability claims, the rotator cuff problem.
 
 Nancy Cavey [00:08:25]:
 Let's take a break.
 
 Speaker B [00:08:27]:
 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 youf 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 [00:09:02]:
 Welcome back to Winning Isn't Easy Rotator cuff disorders and your long term disability claim. Now, the rotator cuff is a group of four muscles and tendons that surround the shoulder joint. They keep the ball of the humerus securely in the socket, and they allow you to lift and to rotate your arm. Think about the motion that a pitcher makes when the rotator cuff is damaged. Everything from brushing your teeth to working overhead can become excruciating. Rotator cuff problems are common, and they can include tendinitis, bursitis, partial or full tears, and shoulder impingement. And these issues can develop gradually from repetitive stress, like years of lifting or like I did swimming, or suddenly from an injury now mine occurred over time because of the repetitive motion of a swimmer. Carriers often underestimate the disabling nature of rotator cuff problems.
 
 Nancy Cavey [00:09:55]:
 They're going to look for certain things in your medical records like X rays, MRIs, and an MRI arthrogram to confirm the tear, the location of the tear, the severity of the tear. They're going to look at treatment notes to see what physical therapy you had in your response to that. They'll look for preoperative injections and your response to that. And of course, they're going to be scrutinizing the operative report to see what was found objectively at the time of surgery. Now, they will expect steady improvement postoperatively. And if you haven't had surgery, they're going to argue that your condition must not be severe enough. But either way, with surgery or without surgery, they're going to use disability duration guidelines to, to suggest that you should have gotten better by now. But the reality is different.
 
 Nancy Cavey [00:10:47]:
 I will tell you that rotator cuff surgery is painful. And particularly the physical therapy where you're doing these crawls with your shoulder, with your fingers, trying to go up the wall, and it's excruciating. It can take months or even years for a full recovery from a rotator cuff tear. And then start. Some people just don't regain full function. There can be pain, there can be stiffness, there can be loss of strength, and that can linger long after surgery despite physical therapy or injections. Even so, carriers may get on the phone with you and say, hey, what is it that you're doing in the course of a normal day? Do you have a dog? Hey, tell me about Fido. How much does Fido weigh? Do you take Fido on walks? And, and, you know, I bet Fido gets bass.
 
 Nancy Cavey [00:11:37]:
 And, you know, Fido's a big dog. You know, how, how heavy is that dog food that you're carrying into the house? And so obviously they're going to be asking you questions about the functionality of your shoulder based on things that are in your activity of daily living forms, things that might be on your social media account or things that are in your medical records. And what they'll do, obviously is twist your words or twist what's seen, heaven forbid, on social media into evidence of improvement. So here's what I suggest you do. We want to document not only your symptoms. So you may have loss of strength, but you want to discuss in some documentation how that loss of strength impacts your occupational functioning. So I tell my clients, I want you to think backwards. What were the occupational duties that you can no longer perform because of your rotator cuff injury or its treatment? And can you do things like reaching overhead? Can you lift light weights repetitively? Can you type or write for an extended period of time where you have your hands out, extended on a keyboard, where your shoulder is in a practically static position? So you want to make sure that, that you are documenting the symptoms, be they loss of range of motion, loss of strength, weakness, maybe even sometimes tingling.
 
 Nancy Cavey [00:13:07]:
 All those symptoms are important, but just as important is to document the functionality. Why is that important? Well, one, you want to keep a copy of it so that you can give it to your physician. But two, as appropriate, you may want to give it to the disability insurance carrier. Now I have found that disability insurance carriers or plans like to use not so independent medical exams or not so independent functional capacity evaluations. We need to first start with what that policy or plan says. Do they have the right to an ime? Generally they do. Is an IME a functional capacity evaluation? Generally not. But you've got to look at the terms of the policy that define the carrier's right to have you examined by someone.
 
 Nancy Cavey [00:13:54]:
 Normally it's a physician or provider of their choice. The frequency with which they get to have that so that you know that in fact they have the right to ask for that. Now again, you need to understand that that goal is not to help you, it's to deny your claim. And in my view, that's when you definitely need legal guidance. So you can understand here that the carrier doesn't necessarily understand the anatomy of the shoulder. They don't necessarily understand what a rotator cuff tear is. They don't necessarily understand how it impacts your functionality without treatment, aggressive treatment, or without surgery. And they certainly don't understand the post operative recovery process.
 
 Nancy Cavey [00:14:41]:
 I've had a number of cases where the client has had multiple shoulder surgeries and, and the carrier just does not understand why that first surgery didn't work or why that second shoulder surgery didn't fix the problem. So again, documentation is really key. You working with your physician to make sure that the medical records explain the story objectively of what's wrong with your shoulder and explain your symptoms and explain your functionality explanation and why those are causally connected. And of course, ultimately connecting that to your restrictions and limitations really is key. Got it. Well, we're going to turn to another condition that's just as disabling and that carriers also misunderstand, and that's called the frozen shoulder. Welcome back to winning isn't easy. Let's talk about frozen shoulders and long term disability claims.
 
 Nancy Cavey [00:15:46]:
 Now, frozen shoulder or adhesive capsillitis is exactly what it sounds like. The shoulder joint that becomes so stiff and painful that it feels like it's frozen in place. The capsule around the joint contracts and forms scar tissue that severely restricts the range of motion. This condition is common in people between 40 and 60 and occurs more frequently in women. It can develop after an injury, surgery, or sometimes with no trauma at all. Now, diabetes, for example, is a known risk factor, as are autoimmune conditions and other medical conditions that can result in a frozen shoulder. The pain and stiffness of a frozen shoulder can be overwhelming. My clients will often describe it as trying to move through concrete.
 
 Nancy Cavey [00:16:33]:
 Sleep becomes very difficult. Daily activities feel impossible. And the condition can progress through three different stages. First is what we call the freezing stage. There's a dull pain and increasing stiffness. Two, there is the frozen stage, where the pain can ease slightly but movement is extremely restricted. And then there's what we call the thawing stage, the slow return of mobility, which can take years, if at all. Now, carriers often seize on the idea that the thawing, as it occurs, is the equivalent of improvement and that you're no longer disabled, even though the range of motion may still be extremely limited.
 
 Nancy Cavey [00:17:18]:
 I will tell you that in my experience, about 10% of cases that we have with frozen shoulders don't resolve without surgery, leading to permanent damage. And so most of these cases will end up with some form of surgery. Now, carriers also miss the secondary symptoms associated with frozen shoulders. That's neck pain, upper pain and forearm pain, stiffness, numbness, and even sometimes headaches. These symptoms can interfere with bilateral manual dexterity, which is, you know, the use of both of your arms. And that's obviously essential to doing most occupations. Just like rotator cuff claims, carriers are gonna look for objective testing. They're gonna look for MRIs, MRI, arthrograms, x rays.
 
 Nancy Cavey [00:18:07]:
 They're gonna expect conservative treatment, rest therapy, medication, and injections. Now, if this is going on for a while, and you aren't having surgery. They're gonna argue that your condition just isn. And if you have surgery, they're going to expect full recovery within their guidelines. Again, so you have to understand what's the strategy here? Again, it comes down to documentation, not only of the frozen sensation, if you will, the pain, the stiffness, and the limited range of motion, but we need to have an understanding of how those symptoms impact your ability to do your own or any occupation. Do you have difficulty, obviously, putting your arm out in front of you as if you were keyboarding, putting your arm out over your head, to the side or behind you? It's the functionality of your shoulder that you need to be explaining to your physician, and your physician needs to document the objective basis for those functional restrictions and limitations. Got it. Well, let's go on in our next segment to shoulder instability and dislocations.
 
 Nancy Cavey [00:19:15]:
 We've got a lot of things to say about that, particularly even in cases of ehlers. Danlos. Got it. Let's take a break.
 
 Speaker B [00:19:23]:
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 Nancy Cavey [00:20:12]:
 Welcome back to Winning Isn't Shoulder instability and dislocations and your ERISA disability claim. Now, shoulder instability occurs when the joint becomes loose, either because of trauma or the degenerative changes or even repetitive strain. Patients will tell you that they feel like their shoulder is about to pop out, a sensation sometimes called a dead arm. And. And in severe cases, the shoulder actually dislocates, meaning that the humeral head slides completely out of the socket. There are three types of dislocations, and I don't think the disability carriers understand this. The first is anterior, the second is posterior, then the third is inferior. Once the shoulder has dislocated, by the way, it's prone to happening again, creating a cycle of instability and damage.
 
 Nancy Cavey [00:21:01]:
 I have clients who will just roll over in bed and the shoulder will dislocate. Now, I will tell you that disability insurance carriers and plans often misunderstand the seriousness of instability and dislocation. They expect that after initial treatment, rest, therapy, injections, you're going to recover. And if you don't they're going to argue that you should have surgery and that surgery would have fixed the problem. And of course, if you don't have surgery, they're going to whipsaw that and say, oh, well, it can't be that bad. But as I've said, repeated dislocations can happen even with minor movements. Rolling over in bed, reaching for a cup, typing it desk. This unpredictability can make work practically impossible because you may not be able to work safely, you may not be able to do just simple routine tasks that your employer would expect that you be able to do.
 
 Nancy Cavey [00:21:53]:
 And obviously this can result in you being off task and ultimately missing time from work. What are carriers looking for in these types of claims? Well, they're going to be reviewing, first off, your therapy notes. There's a wealth of information in physical therapy notes and sometimes I have to remind my clients not to be so vocal about their activities. You know, physical therapists are nice people. They ask, you know, how are you doing? What are you doing? What are you able to do with your shoulder? What problems are you doing? And you know, you might have gone to Disney for the weekend and gotten on a ride that you probably shouldn't have gotten on or you know, pushed your child in a stroller or done some other type of activity that's not necessarily consistent with what's really going on with your shoulder. The display carrier is going to seize on that type of activity and say, well, wait a second, what they're doing is inconsistent. They really can't be as bad off as they say they are. And by the way, you know, I think we maybe should put some surveillance on them or go, let's go look at their social media stuff.
 
 Nancy Cavey [00:23:09]:
 And so again, this is really important. I also want you to remember that after two years, the definition of disability changes from an inability to do your own occupation to an inability to do any occupation. And as a matter of course, basically you have to prove that you can't even do sedentary work using bilateral manual dexterity. And I said you, because ultimately disability carriers will have your medical records reviewed and cherry picked by their liar for hire doctors who will say, yeah, you know, you may have some problems, but you're still able to do some sort of a sedentary job. You are still able to use your shoulder in some way function, and you could do, you know, sedentary type work. And therefore we're going to deny your claim, even though you actually may be a one armed policyholder, if you will, based on the functionality of your shoulder. Now, if that sort of game starts to be played, you should do a couple things. Obviously, you should be consulting with an experienced service and disability attorney.
 
 Nancy Cavey [00:24:19]:
 But if you haven't been, you really need to have your doctor document your functional restrictions and limitations. It might be that you need to undergo some repeat diagnostic studies to show the continued severity and problem of your shoulder. Or you might want to undergo a functional capacity evaluation, which is an objective measure of the function of your abilities. And they will test your ability to, to use your arm, the range of motion, the strength, you know, those sorts of things. Because at the end of the day, you need to protect yourself. Ultimately, if this claim is denied for any of these shoulder conditions, you only have 180 days in which to file an appeal and the appeal is the trial of your case. You need to put forward every piece of evidence and before you do that, obviously you need to get a copy of the claims file because you want to understand what their medical providers had say about your shoulder condition, your functionality, what your restrictions and limitations might be so that you can go about challenging it. Your attorney should obviously not only get a copy of that file, but your medical records reading both in conjunction, cover to cover to understand.
 
 Nancy Cavey [00:25:37]:
 Well, what are the weaknesses or problems in this case and what's our strategy going to be? Often in my ERISA disability cases, I use shoulder residual functional capacity forms because I'm also a Social Security disability lawyer. These forms ask the right questions about the functionality of a person's shoulder, not the kind of APS questions that you see in the forms that they want your doctors to fill out. I often use that as a starting point for taking apart the carrier doctor's opinion. I wanted to know, did they think about this problem, this problem, this problem? What is it they had to say? Is that consistent with what your doctor had to say? Do we need to get a functional capacity evaluation to address all of these bogus cherry picked reasons that the carrier's doctor has come up with, or do we need to get an ime? And ultimately, of course, we need to tie this all together. We need to establish the objective basis of the restrictions and limitations. But from a vocational standpoint, we need to attack their opinion that you could do your own occupation, or any occupation based on the physical requirements of each. You can see that this is not a simple matter. Carriers don't understand shoulders.
 
 Nancy Cavey [00:26:53]:
 They don't understand the anatomy, the diagnostic studies, the results of the testing, the treatment, the complications of surgery, and the postoperative functional limitations. And of course, if your shoulder condition is painful, you're going to be taking pain medication and disability carriers just don't understand the side effects of pain medication on top of the pain and discomfort that you already have. Got it. This isn't an easy area, and carriers will screw this one up all the time. Thanks for listening. Today's episode of Winning Isn't Easy. If you found this episode helpful, please take a moment to like our page, leave a review, share it with your friends and family and and of course, subscribe to this podcast. Join us next week for another insightful episode of Winning Isn't Easy.
 
 Nancy Cavey [00:27:43]:
 Thanks for listening.