It can be difficult to get long term disability (LTD) insurance benefits for mental disorders, which include cognitive, emotional, psychological, and psychiatric problems.
You may be eligible for LTD disability benefits for both physical and mental medical conditions, but it is usually harder to collect disability benefits for a mental illness than for a physical illness. Why? Part of the reason lies in the nature of mental illness itself. Mental health illnesses and associated symptoms are not likely to be easily assessed, and the severity of the condition may be hard to measure objectively.
Evaluating Mental Illness
What Is a GAF Score and What Does It Have To Do with My Disability?
GAF stands for Global Assessment of Functioning, and it is a rating or score on a scale of one to one hundred. The GAF rating “is a subjective determination of the physician’s judgment (on a 100-point scale) of the claimant’s overall ability to function on that particular day, excluding physical and environmental impairments.” Long v. Astrue, 2009 WL 5033973, at *1 n.1 (E.D.Pa. Dec. 21, 2009) (Pollak, S.J.)(citing Diagnostic and Statistical Manual of Mental Disorders IV-TR (“DSM-IV”), at 34 (4th ed. 2000). A GAF score of 50 “indicates a serious impairment in social and occupational functioning.” Escardille v. Barnhart, 2003 WL 21499999, at *2 (June 24, 2003) (Giles, C.J.)(citing DSM-IV at 34).
However,a GAF score is a snapshot in time. It only reflects how the patient is doing at a particular time on a particular day. Thus, a claimant’s GAF score at a particular time, while reflecting his or her individual functioning at that time, does not reflect his or her functioning at another time.
What Is a Mental Residual Functional Capacity Assessment and What Does It Have To Do With My Disability?
To learn what your residual capabilities are, the insurance company may ask for you to take an Attending Physician’s Statement (APS) form to your doctor (this form is also known as a Residual Functional Capacity form). If the insurance company claims handler does not believe the APS is sufficient (for example, if the doctor’s responses on the form are totally inconsistent with the medical records in the claim), the adjuster may schedule you an appointment to attend an “Independent Medical Examination” by a doctor hired by the insurance company. This doctor will then perform an RFC (residual functional capacity) assessment for your claim. The examiner will determine what level of exertion you are capable of performing, and what restrictions you have that may limit the jobs you can do. The medical examiner may also review your medical records and your doctor’s notes about your functional abilities and restrictions to come up with your RFC.
How Insurance Companies View Mental Claims
Disability claims examiners who work for long term disability insurance companies are not licensed psychiatrists or psychologists, and thus they do not always understand the full scope of the limitations imposed by certain mental illnesses.
For example, some disability examiners do not recognize the cyclical nature of certain mental illnesses, such as bipolar disorder or manic depression, and therefore the insurance agent may presume a patient is cured because he or she does not currently display certain symptoms. However, in reality, those symptoms have just dissipated for the moment, and are almost certain to return in the near future.
In addition, some disability claims examiners are biased against disability claims for mental illness.
Mental Impairments That Would Qualify for Long Term Disability
Mental impairments that may be eligible for long term disability benefits include:
- affective disorders;
- anxiety;
- schizophrenia, paranoia, and other psychotic disorders;
- depression;
- bipolar disorder;
- somatoform disorders;
- personality disorders;
- organic mental disorders; and
- substance abuse disorders.
This list is not complete. These are simply the most common cognitive, emotional, and mental disorders that may qualify for mental illness.
Affective Disorders
The specific requirements to qualify for long term disability benefits vary with the type of affective disorder. In general, a claimant must have medical documentation showing that the affective disorder affects the claimant’s ability to function despite undergoing treatment for the disorder. The claimant should submit medical documentation giving sufficient evidence that the claimant’s condition hinders the claimant from reasonably being expected to function in any work environment.
Anxiety Disorders
To qualify for long term disability benefits with an anxiety disorder, the medical evidence should show that the claimant has at least one of the following:
- Persistent anxiety with appropriate symptoms (i.e., motor tension, apprehensive expectation, etc.),
- A constant irrational fear,
- Recurring, unpredictable panic attacks occurring on a regular basis,
- Recurring compulsions and obsessions leading to significant distress,
In addition, the medical evidence on record in the claim should show that these conditions significantly impact the claimant’s ability to function in normal work and social conditions.
Organic Mental Disorders
To qualify for long term disability benefits with an organic mental disorder, the medical evidence should show that the disorder hinders the claimant from performing even basic work functions. The claimant would need to show that the claimant cannot function outside of a highly supportive environment. Alternately, a claimant may qualify if he or she can show one or more of the following impairments:
- Time and place disorientation,
- Significant limitations of daily living activities,
- Impaired memory (short or long term),
- Significant limitations or impairments in social situations,
- Hallucinations or delusions,
- Difficulty concentrating or keeping pace,
- Personality changes,
- Extended and repeated periods of decompensation,
- Mood disturbances, and/or
- Lability of emotions.
Personality Disorders
To qualify for long term disability benefits with a personality disorder, the claimant needs evidence showing that the claimant’s condition causes the claimant to be unable to adapt to social or work situations and that the condition has caused long term problems. The disorder should demonstrate at least one of the following symptoms:
- Autistic thinking,
- Seclusion,
- Inappropriate hostility,
- Inappropriate suspiciousness,
- Odd thought, speech, behavior, or perception patterns,
- Aggressiveness,
- Dependence,
- Passiveness,
- Constant mood disturbances,
- Impulsive, damaging behavior, especially regarding relationships,
Psychotic Disorders (including Paranoia and Schizophrenia)
To qualify for long term disability with psychotic disorders, the claimant should have medical documentation showing that the claimant’s condition severely limits his or her ability to function in a work environment. The documentation should show that any change in the claimant’s work situation would lead to more problems or that the claimant is incapable of living outside of a supportive environment. Alternately, the claimant may qualify if he or she has one of the following conditions and the claimant can show that it severely affects the claimant’s ability to function in a work or social environment:
- Hallucinations,
- Delusions,
- Catatonia,
- Disorganized behavior,
- Incoherence,
- Illogical thinking,
- Speech significantly affected by blunt effect, inappropriate affect, or flat affect, and/or
- Isolation and emotional withdrawal
Somatoform Disorders
To qualify for long term disability with a somatoform disorder, the claimant needs medical documentation showing that, by age 30, the claimant had a history of having unexplained physical symptoms which lasted for several years and that these symptoms require the claimant to make significant changes to his or her lifestyle. The claimant may qualify for LTD disability benefits if the symptoms involve loss of sight, hearing, speech, loss of movement, loss or heightening of sensation, or loss of use of one or more limbs.
Other Mental Disorders
Other conditions that may qualify for disability benefits under a mental disorders evaluation include:
- Attention Deficit Hyperactivity Disorder,
- Asperger’s Syndrome,
- Bipolar Disorder,
- Chronic Insomnia,
- Depression,
- Dysthymia,
- Eating Disorders,
- Hallucinations,
- Memory Loss,
- Mood Disorder,
- Obsessive Compulsive Disorder,
- Panic Attacks,
- Postpartum Depression,
- Post Traumatic Stress Disorder and
- Social Anxiety.
If you have been diagnosed with a mental condition that is preventing you from working and your mental RFC (residual functional capacity) shows you have intellectual, social, or functional limitations, you may be eligible for disability.
If you are unable to work as a result of a mental disorder, you should consult with an experienced long term disability attorney. Unfortunately, long term disability carriers do not make it easy for disabled claimants to receive the benefits that they deserve. If your mental disorder makes it impossible for you to work and you have been denied your long term disability benefits, the legal team at Ortiz Law Firm can help you cut through the red tape and fight for your disability benefits no matter where you live in the United States. Give us a call today to discuss your claim at (888) 321-8131.