Patients with polymyositis may be unable to work because of their disease and its related complications. Patients who find themselves unable to work because of their polymyositis may qualify for long term disability (LTD) benefits. The insurance company will review their claim to see if they qualify under the conditions of that plan.
What is Polymyositis?
Polymyositis is a rare inflammatory disease that causes weak muscles on both sides of your body. This disease can make it difficult for you to reach overhead, lift objects, rise from a seated position, or climb stairs.
Polymyositis is most commonly found in adults between the ages of 30 and 60 and occurs in black people and women more often than white people and men. Symptoms usually develop gradually over time, from several weeks to several months.
The medical field has yet to discover the exact cause of polymyositis, but it acts like autoimmune disorders, where your immune system will mistakenly attack your own body tissues. There is no cure for polymyositis, but treatment can help you improve your muscle function and strength.
Disability Evaluation of Polymyositis
Long term disability insurance companies refer most often to the Center for Disease Control (CDC) to evaluate polymyositis. The CDC recognizes polymyositis if it drastically interferes with your personal, social, work, or school activities, has no other known physical or mental cause, and has a definite onset date. Diagnosis also requires four or more of the following symptoms for at least six months:
- Breathing issues – When chest muscles are affected by this condition, you might have trouble breathing including shortness of breath or respiratory failure;
- Difficulty swallowing – If polymyositis affects your esophagus, you may have dysphagia, or trouble swallowing. This can lead to malnutrition and weight loss;
- Aspiration pneumonia – Because you may have difficulty swallowing, you could breathe food or liquids, including saliva, into your lungs. This is known as aspiration and can lead to pneumonia; and
- Muscle weakness – Polymyositis causes weakness in muscles closest to the trunk, including your neck, upper arms, shoulders, thighs, and hips. The weakness affects both sides of the body and worsens over time.
Any medical documentation turned in with your application must show the above criteria and prove that your symptoms didn’t start before the onset of your polymyositis.
Long Term Disability and Polymyositis
The LTD company bases its decision on the information you and your doctors provide during the application and appeals processes. The following information will give you tips on what the insurance company is looking for when evaluating your LTD claim based on polymyositis.
Definition of Disability
You are considered disabled under most LTD policies if you are (1) unable to perform your work duties at your current occupation for the first two years of the policy, and (2) unable to perform the job duties of any occupation you might qualify for after the first two years of the policy. The disability definition varies with each individual policy, so please review your own long-term disability policy to find out how “totally disabled” and “disability” are defined in your specific case.
Proof of Polymyositis
To apply for LTD benefits, you must submit medically acceptable laboratory and clinical findings to prove the existence of polymyositis. While the effects of your symptoms may be considered during the insurance company’s disability decision, symptomatology and a simple diagnosis are not enough for approval.
Evaluating Disability for a Polymyositis Diagnosis
The LTD insurance company will assign an insurance adjuster, also known as an adjudicator, to your claim. They may work with the help of a psychologist, physician, or another medical disability examiner such as a nurse practitioner to provide an opinion about your level of impairment. You may also be required to have a compulsory medical examination or a functional capacity evaluation. The insurance adjuster then uses all the available evidence, including the impact of the disorder on your body and any treatment since the onset of the disorder, to make an informed decision.
If the adjuster doesn’t have enough evidence to work from in order to make a formal decision, he or she may contact you for additional information. You can submit this information yourself if you have it. Otherwise, the adjuster may contact an independent medical source.
While your physician may diagnose your polymyositis using your stated symptoms, your diagnosis will need to be backed up with medical test results to qualify for long-term disability. The insurance company requires reports documenting your objective laboratory and clinical findings, so your doctor should turn in all available evidence concerning your condition, even if it points towards another disorder.
Work With an Experienced Long Term Disability Attorney
Working with an experienced disability attorney will give you the best chance of getting the benefits you deserve for your polymyositis. Even if you have been denied benefits, that does not mean your fight is over. Many people are denied benefits the first time they apply. You have the right to file an appeal and try to get more information that may help your case. Getting expert help is often the difference between being denied and being approved for benefits.
While the process can be daunting, your experienced disability attorney will be able to guide you through the process. They do not get paid until you win your case. You can seek help without worrying about upfront costs or unexpected bills.
The Ortiz Law Firm has successfully represented people in disability cases across the United States. If you would like to talk to an experienced disability lawyer about your polymyositis and its impact on your ability to work, call us at (888) 321-8131. We would be happy to evaluate your case and to discuss how to help you through the appeal process.