When Policy Limits Collide - Navigating Mental Nervous and Musculoskeletal Conditions in Long-Term Disability Claims

Welcome to Season 5, Episode 41 of Winning Isn't Easy. In this episode, we'll dive into the complicated topic of "When Policy Limits Collide - Navigating Mental Nervous and Musculoskeletal Conditions in Long-Term Disability Claims."

Most people think a Long-Term Disability claim is decided by the diagnosis alone - that if you’re struggling with a mental health condition, chronic pain, or cognitive impairment, your insurer should simply recognize it. But LTD claims hinge on far more than the condition itself. Carriers scrutinize how your symptoms affect daily functioning, the consistency of your treatment, and how your providers document limitations. Even then, many claims get funneled into restrictive policy clauses that quietly cap benefits at two years. In this episode, we break down the medical side of LTD claims involving mental nervous and musculoskeletal limitations - an area full of misconceptions and insurer tactics that can derail legitimate claims. We start with caregiving responsibilities and daily activities, and how routine tasks can be used to undermine a mental nervous claim. Then we explore the blurry divide between physical and psychological impairments, using post-concussive syndrome to show how insurers reclassify conditions to fit benefit caps. Finally, we examine musculoskeletal limitations and how vague policy language lets carriers argue that chronic pain, spine conditions, or soft-tissue injuries don’t qualify for ongoing benefits. By the end, you’ll see why navigating these claims requires more than treatment - it demands precise documentation, strategic communication, and a clear understanding of how insurers evaluate evidence. This episode gives you the tools to protect your benefits and anticipate the carrier’s playbook.

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

One - How Taking Care of Your Spouse Can Destroy Your Mental Nervous Disability Claim

Two - When Physical Injuries Get Reclassified as Mental Disorders

Three - The Hidden Risk of the Musculoskeletal Disorder Limitation

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 Risk and individual disability attorney. Welcome to Winning Isn't Easy. Before we get started, I've got to give you that legal disclaimer that this podcast is not legal advice. The Florida Bar association says I have to say this and I've done that. Now I will assure you that nothing will prevent me from giving you an easy to understand overview of the disability insurance world, the games the carriers play, and what you need to know to get the disability benefits you deserve. So off we go now. Understanding the medical side of a long term disability claim can be the difference between getting your benefits and being denied or having your benefits terminated.
 
 Nancy Cavey [00:00:55]:
 Carriers are not just going to look at the diagnosis. They're going to scrutinize your report of your symptoms, how those symptoms impact your ability to function and the nature of the treatment you're getting, and what impact that has on your ability to do your own or any occupation. They are definitely going to read your medical records line by line and they're going to pay close attention to what your medical records say, how your providers describe your limitations, and whether your condition could be reclassified under a policy limitation. What do I mean here? Well, most mental, nervous and physical disability claims go through multiple stages and at each stage the carrier or the plan administrator is going to examine the records. They may request additional information from you, or they may ask their liar for hire peer reviewed doctors to review the records and then to reach out to your medical providers. Their goal is not to confirm your diagnosis, but to see whether the evidence meets the policy definition of disability, whether they can limit or cap your benefits based on mental, nervous or musculoskeletal clauses and convince your doctor that you are miraculously cured and capable of doing your own or any occupation. So this is why today's episode is about answering questions about navigating claims and particularly claims involving mental nervous conditions and related policy limitations for not only mental nervous conditions but subjective medical condition limitations. And I'm going to do this in three parts.
 
 Nancy Cavey [00:02:32]:
 First, I am going to talk about how caregiver responsibilities for family members or daily activities can weaken a psychiatric mental nervous claim. Then I'm going to tackle that tricky line between physical and mental conditions. And I'm going to use a post concussive syndrome case as an example as to how disability carriers are going to change, if you will, or reclassify the nature of your disability to limit benefits. And then I'm going to talk about musculoskeletal disorder limitations or subjective policy limitations. Can leave you with benefits that are limited to just 24 months. So my goal here is to help you understand why mental nervous and musculoskeletal claims are far are about far more than your medical condition. It's about evidence, it's about documentation, it's about strategy. You'll hopefully know how carriers and plans are going to analyze your case and what you need to do from the very beginning to protect your benefits.
 
 Nancy Cavey [00:03:44]:
 So let's get going. So number one, how taking care of your spouse can destroy your mental nervous disability claim. Number two, when physical injuries get reclassified as mental disorders and what you need to do and number three, the hidden risk of musculoskeletal disorder or subjective medical condition limitations. Let's take a break for a moment before we get back into this episode.
 
 Speaker B [00:04:09]:
 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. Let's talk about how taking care of your spouse can destroy your mental nervous disability claim. So do you have anxiety, depression, post traumatic stress disorder? Have you applied for your short and long term disability benefits? Did you review your medical records before you submitted the claim? Do you know whether your mental health provider supports your claim? And if not, there can be big problems ahead. So let's talk about crucial mistakes that you can make in a mental nervous disability claim. When you apply for those benefits, the carrier or the plan administrator is going to obtain and review your medical records and they're going to ask your medical provider to complete forms such as a behavioral questionnaire. And what are they looking for? Well, what they're looking for is the history of your symptoms, the onset of your symptoms, any employment related causes for these symptoms, any family related causes for these symptoms. They're going to be looking for a description of how your symptoms impact your daily functioning. They're going to be looking at your level of social functioning.
 
 Nancy Cavey [00:05:53]:
 They're going to be looking at the results of mental status examinations conducted by your provider. And guess what? They're going to ask your treating provider to describe your condition, your social functioning, your responses to medication and any test results, what's in your medical records and what your provider writes on those attending physician statement. Behavioral forms can heavily influence whether your benefits are approved or denied. So let me give you an example. Let's talk about the case of Rubin versus Life Insurance Company of America. Now, this is an 11th Circuit case. I'm in the 11th Circuit. The 11th Circuit is a bit conservative.
 
 Nancy Cavey [00:06:34]:
 So you need to obviously understand your circuit's proclivities in an ERISA claim so you understand how they're going to look at an appeal in this case. Ms. Rubin was a telephone sales representative and she stopped working in 2021 because of depression and anxiety, depending on she applied for her short term disability benefits, which were denied by Lena. And her treating psychologist described her social functioning as improved. That didn't help. But the psychologist also attributed her inability to work to her need to take care of her husband. The psychiatrist agreed that she couldn't work, but didn't explain how her depression and anxiety prevented her from working, apart from, of course, her caregiving responsibilities. And this was a costly mistake because the carrier's physicians concluded that her medical records didn't show a psychiatric impairment.
 
 Nancy Cavey [00:07:29]:
 Her mental status exams were normal. And I will tell you, I hate the many mental status exams that psychologists, social workers, psychiatrists use because they really are generally normal. But that normal mini mental status exam doesn't reflect the degree of your functioning, which in my view is really the crucial issue here. And the problem also in this case was that the medical records didn't provide any clear evidence of her functional limitations as a result of her anxiety or depression or whatever problem she was having. When was she having any problems interacting with her family members? Was she having any problems interacting with the public? Was she having difficulty following instructions? Did she have problems with isolating herself, with lack of self care, with feelings of guilt or self worthlessness? And how did all of those symptoms impact her ability to function? But in this particular case, her caregiving role suggested functional capacity. And guess what? The carrier did. Their medical director, a psychiatrist, spoke with Rubin's treating psychologist in a peer to peer call that only reinforced these impressions. The treating psychiatrist also confirmed that Reuben could care for her husband and could not provide examples of tasks that she would unable to to be to perform.
 
 Nancy Cavey [00:09:02]:
 From a psychological standpoint notwithstanding, she could provide care for her husband. The records showed she had been overseeing a condo renovation and had been going to the gym, which were activities, in the carrier's view, that indicated no psychiatric impairment. And I would probably agree. Look, if you're interacting with workers who are general contractors and subcontractors on a condo renovation, you're interacting with people, you're making decisions, you are basically probably having more than adequate social functioning, same way with going to the gym, unless of course, you were having a problem with the members of the gym, which was not documented in the medical records. So Reuben lost in federal court and ultimately 11th Circuit appeal was taken. The 11th Circuit in this case used the de novo standard of review, which means they could substitute their judgment for that of the federal judge. And even with that favorable standard of review, the court agreed that the decision to deny the claim and terminate benefits was reasonable based on the evidence. Now, what was worse is that she had the chance to respond but didn't do so in a meaningful manner.
 
 Nancy Cavey [00:10:18]:
 A stronger approach would have been to submit sworn statements to describing her daily limitations, having her husband give an affidavit and statement about how she had trouble with the caregiving function from a psychological standpoint, and also how her caregiving role affected her functioning. Have her family and friends who may have observed her address those particular issues, particularly going to the gym or interacting with the contractor? She may have had trouble interacting with the contractor, but who knew? And of course, the carrier drew speculative conclusions that helped their case. And obviously her psychiatrist should have addressed these issues in a meaningful fashion. You have to understand that providing care for a spouse can be inconsistent with disability allegations and particularly the activities that she did with regard to the condo. The medical documentation has to address how you can do these things but still remain disabled and unable to do your own occupational duties. So when you're filing a claim for a mental nervous condition, you need to make sure that your provider is explicitly connecting your symptoms to your inability to perform your occupational duties, not just to life stressors or family demands. It's the clarity and medical specificity can make all the difference between an approval, a denial, and a termination. Got it.
 
 Nancy Cavey [00:11:46]:
 Let's take a break. Welcome back. Let's talk about when physical injuries get reclassified as mental disorders. Now, this is a game that disability carriers play with all sorts of medical conditions. But in this case, we're going to talk about a post concussive syndrome. According to the Mayo Clinic, post concussive syndrome, PCs can result from a mild traumatic brain injury such as a concussion. And these injuries can occur from a fall, a car accident, contact sports, or a violent shaking of the head or the body. You don't need to lose consciousness to develop PCs.
 
 Nancy Cavey [00:12:34]:
 And the severity of the injury does not necessarily determine either the symptoms or how long those symptoms last. But what are the common symptoms that we see, whether headache, dizziness, and problems with concentration or memory. And that can persist for months or even years. So the question becomes, is PCs a mental nervous condition or an Organic physical condition. And the answer will matter. If PCs is labeled as a mental nervous condition, benefits can be limited to just two years. If it's classified as a physical condition, benefits can continue so long as a disabling condition persists and meets the policy definition terms of disability. And that question was at the center of a case, hall versus Reliance standard.
 
 Nancy Cavey [00:13:20]:
 So let me tell you Ms. Hall's story. Ms. Hall was a registered nurse who was seriously injured in a car crash. She suffered a concussion, post concussive syndrome, traumatic brain injury, post traumatic stress disorder, headaches, dizziness, neck pain, numbness and back pain. So Reliance Standard approved her claim, but invoked the mental nervous limitation after 24 months, arguing that her disability was not physical, but it was psychiatric. So how did the policy define mental or nervous disorder? And this is really key. The policy listened.
 
 Nancy Cavey [00:13:54]:
 Bipolar disorder, schizophrenia, delusional or paranoid disorders, psychotic disorders, depressive and anxiety disorders, somatoform and eating disorders, and general mental illness as being covered under this mental nervous policy limitation. But guess what? There was no mention in this definition of post concussive syndrome. So what did Reliance Standard do? They hired a neuropsychologist who reclassified her condition as a somatic symptom disorder and chronic post traumatic stress disorder. And this tactic is common. They're going to shift that physical diagnosis into a psychiatric one once the policy limitation applies. Now, what happened? Unfortunately, in this case, Reliance Standards decision was upheld under the arbitrary and capricious standard of review, which requires that only the insurer's interpretation be reasonable, not necessarily correct. Hall argued that her cognitive problems stem from the physical brain trauma. But the court accepted Reliance Standards reasoning and reliance on its own medical reviewer stinky decision.
 
 Nancy Cavey [00:14:59]:
 So what are the takeaways from this case? Well, number one, under erisa, insurers and plan administrators can rely on their own consultants. They aren't required to favor the opinion of a treating physician. So in other words, there's no treating physician. Rule number two, when a policy says benefits are limited for conditions caused or contributed to by a mental disorder, this language gives the carrier wide latitude to reclassify the condition. And I call this the Monty Python mental nervous policy limitation. Obviously, she had some psychological issues as a result of the injury. But if there was caused or contributed to language, if that depression or that anxiety or that post traumatic stress disorder contributed ever so small, ever so slightly to her disability, benefits were going to be limited to just two years. So what should we be doing here? Well, if your disability arises from a head injury, we want to one make sure that your doctor clearly documents the physical source of your symptoms.
 
 Nancy Cavey [00:16:08]:
 Two, that they document the neurological source of your symptoms, and that can involve diagnostic testing. Number three, they want to document both the physical symptoms that you have and potentially the neurological symptoms that you have. And we want to make sure that you're giving a really good history of your symptoms and functionality. Now, I find with my TBI clients that they don't really do a good history. They're not good historians. And so often times it's a family member who's keeping a log of the symptoms that they're having. The problems with memory, the problems with concentration, the problems with emotional regulation. And that is really important because ultimately we want the doctors to be able to say, look, based on the area of injury to this person's brain, these symptoms that they're having are consistent with that organic physical injury.
 
 Nancy Cavey [00:17:07]:
 They are not psychological in nature. They're. They're not psychologically based. They are in fact organically caused. We don't want the disability carrier plan to reclassify this organic brain condition into a psychiatric condition. Now, there are some pitfalls here. Your doctor may have suggested that you have neuropsychological testing. And it's not uncommon for people who have problems as a result of a TBI to also be depressed and have anxiety.
 
 Nancy Cavey [00:17:41]:
 Sometimes these neuropsychological tests will kind of try to parse out what the organic cause is, the damage to the executive functioning. But they also kind of address the depression and the existence of the depression and the nature of the impact that the depression or anxiety has on a person's psychological functioning. Before that neuropsychologist goes and does any testing, I always say timeout. We want to review that policy to understand, do we have a mental nervous policy limitation and what is it, what's covered, what's not covered? Is it a cause or contributed limitation? And we want to think about what we want that neuropsychologist to do. Often I will have a pre testing, pre evaluation, consult with a neuropsychologist saying, look, we've got a ERISA claim here. We've got these policy terms. What testing do you think you can do that will tease out the cognitive basis of this disability and not so much concentrate on the psychological issues, but if you want to concentrate on them, you need to understand we've got this Monty Python mental nervous limitation. And so while they may be depressed, we don't really want to say that the depression is going to cause them disability or impact their disability.
 
 Nancy Cavey [00:19:04]:
 And of course, we want to do this in a truthful and honest fashion. But we want to try to address these problems well before this neuropsychological exam happens. And if it's after the fact, we're probably going to have to have a conference with a neuropsychologist to to address their report and of course, the opinions of the carrier or plan's neuropsychologist. You can hear that this is complex and it's going to take potentially a lot of planning and a lot of strategy and potentially a lot of work to reverse the opinions of unfavorable doctors or to address the opinions in a way that shows that this is and remains an organic physical condition. Got it. Let's take a break.
 
 Speaker B [00:19:52]:
 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 [00:20:40]:
 Foreign. Welcome back to Winning Isn't Easy. The Hidden risk of Musculoskeletal disorder or subjective Medical condition limitations. Now, when you bought your disability policy or enrolled in your employer's plan, nobody told you that there would be certain limitations that could cap your benefits to just two years of benefits. And one of the two most common limitations are the musculoskeletal disorder limitation or the subjective medical condition limitation. And typical clauses can read something like this. If your disability is due to mental or nervous disorders, neuromuscular, musculoskeletal or soft tissue disorders, or chronic fatigue syndrome, or fibromyalgia or migraines, benefits are limited to 24 months. Now, this limitation doesn't apply if the claimant provides objective evidence of conditions such as such as radiculopathy.
 
 Nancy Cavey [00:21:36]:
 That's a lot of words here. And we need to review this language and start parsing it. And we have to start parsing it from the very beginning. We want to understand what's the definition of disability? What's the definition of mental nervous disorder? Is there a definition of neuromuscular, musculoskeletal, soft tissue disorders? Is there, is there a definition of objective evidence? And it's the starting point for understanding what it is we have to prove. So let me tell you the case of Penn Land versus Metropolitan Life that will illustrate how this goes down. In Penland's plan, the definition of radiculopathy was diseases of the peripheral nerve root supported by objective clinical findings of neuropathology. Again, a lot of words we've got to parse. MetLife denied his claim, saying that the medical records did not show objective nerve involvement or functional limitation severe enough to prevent work.
 
 Nancy Cavey [00:22:37]:
 Okay, so what did the court find, and why does it matter now? Penland argued that this limitation should apply only if the restricted condition was the sole cause of disability. That was a stretch. And the court agreed that it was a stretch. They disagreed, saying, look, your interpretation would make this limitation meaningless. He pointed to MRI results. He pointed to his physician notes referencing radiculopathy. But the court said, look, we've got subjective pain here, and this inconclusive imaging was insufficient proof. And ultimately, the court upheld this denial.
 
 Nancy Cavey [00:23:13]:
 So there's some lessons that can be learned. So let me give you some practical guidance moving forward. Number one, if you're a policyholder plan participant, get that policy, read it cover to cover, and take apart the words. These words matter. So you want to understand what are the words, what is the definition, and what does this mean in terms of proof? So if, for example, the policy limitation has fibromyalgia and you have fibromyalgia, benefits are going to be limited to just two years. But let's say you have fibromyalgia and, and a herniated disc in your back. You are going to want to understand that after 24 months, your fibromyalgia claim falls away. And the carrier is only going to evaluate your back, but it requires objective evidence.
 
 Nancy Cavey [00:24:02]:
 So you may have had back surgery. The doctor, the neurosurgeon, says you're healed, but of course you've got chronic issues. The question is going to become, okay, what is the post surgical MRI show? Is there still a herniation? Is there encroachment? Is there stenosis? Is there a progression based on subsequent MRIs? Is there an EMG and nerve conduction study test that shows ongoing radiculopathy? What does your physical exam findings show? In other words, what are the objective proof in your claim that would show that you are disabled as a result of, for example, the radiculopathy? But you need to understand that now because after you have the surgery, you want to make sure in this case that your medical evidence is strong enough to show radiculopathy and objective evidence. If you don't have radiculopathy, again, we might have the application of this musculoskeletal limitation or the subjective medical condition limitation. And let's talk about that. The subjective medical condition limitation is another form, if you will, of a limitation and the policy may define certain medical conditions as subjective. So after you've had your surgery but you still have pain, or you have muscle spasm, or you have weakness, or you have tenderness, or you have migraines, or you have body wide aches, all these sort of subjective things, including pain, they're going to say benefits are limited to just two years. So you're going to need solid objective evidence such as MRIs, EMGs, nerve conduction study tests.
 
 Nancy Cavey [00:25:51]:
 I know that in some conditions you're not necessarily going to have objective diagnostic studies like migraines, but you're going to have to have detailed provider statements explaining how the diagnosis was reached, the objective basis for the restrictions and limitations, the objective physical findings, and any diagnostic studies that support the conclusion that you have functional objective restrictions and limitations. You can guarantee to anticipate insurer challenges and you need to be ready to have a strategy to make sure your records are complete and accurate to understand what it is you need to prove to have your physician on board to provide responses that are going to have to address the opinions of the insured hired consultants. I call them liar for hire peer review doctors. So knowing how to document and defend these limitations isn't just good preparation from the very beginning. It's going to really determine whether your long term disability benefits continue or stop at at the two year mark. Got it. Thank you for tuning in to this week's episode of Winning Isn't Easy. I hope you found this episode helpful and if you did, take a moment to like our page, leave a review, share it with your friends and family, and subscribe to this podcast.
 
 Nancy Cavey [00:27:07]:
 Please join us next week for another insightful episode of Winning Isn't Easy. Thanks for listening, Sam.