Patients with osteoarthritis may be unable to work because of their disease and its related complications. Patients who find themselves unable to work because of their osteoarthritis 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 Osteoarthritis?
Osteoarthritis is the most common form of arthritis, which causes pain and swelling of the joints that affects millions of Americans each year.
The condition is sometimes referred to as noninflammatory arthritis or “wear and tear arthritis,” which is different than inflammatory or rheumatoid arthritis. In the case of rheumatoid arthritis, the immune system mistakenly attacks a person’s joints and cartilage resulting in pain, stiffness, swelling, and often disfiguration. On the other hand, osteoarthritis is a degenerative condition that occurs when the protective cartilage on the ends of one’s bones wears down over time. And, unlike rheumatoid arthritis, osteoarthritis is not considered to be an autoimmune disease.
How Does Osteoarthritis Occur?
As a result of age or physical “wear and tear,” a sufferer of osteoarthritis experiences a degenerative breakdown of their cartilage normally in the hands, knees, hips, or spine. Cartilage acts as a barrier that covers the ends of bones in the joints. As that cartilage breaks down, bones can rub against one another causing pain.
When Osteoarthritis Arthritis is a Disability
Osteoarthritis can be a debilitating condition that impacts one’s quality of life and ability to work. Because osteoarthritis is a degenerative joint disease, a person’s condition is expected to worsen over time, often resulting in tremendous pain and limited mobility that prevents a person from engaging in work or even the activities of daily life (ADL).
However, simply being diagnosed with osteoarthritis isn’t enough to be considered disabled. You are considered disabled when a condition limits your normal movements, senses, or activities. A determination of disability is made based on the activities you find difficult. For example, you may have trouble:
- Lifting more than 10 pounds;
- Grasping small objects;
- Standing or sitting for extended periods; or
- Walking upstairs.
Qualifying for Long-Term Disability Insurance
Documenting Your Disability Due to Osteoarthritis Is Essential
The insurance company will base its decision on information obtained from your medical providers and upon any information you provide during the application and/or appeal process. The following will help you understand the kind of information your long-term disability insurance company needs to evaluate your LTD claim based on osteoarthritis.
If you find that your osteoarthritis limits your ability to work, you should work closely with your doctor to document your condition. In order to qualify for long term disability benefits, you will need sufficient evidence detailing how your condition prevents you from working or performing daily tasks that you otherwise would be able to do.
Definition of Disability for Inflammatory Arthritis
Under most LTD policies, an individual is considered disabled if he or she is: (a) unable to perform the material duties of his or her own occupation for the first two years of the policy; and (b) unable to perform the duties of just about any occupation after the first two years of the policy. The definition of disability is specific to each individual policy, so you must review your own LTD policy to determine how the term “disability” or “totally disabled” is defined for you.
Your provider will then determine whether your Osteoarthritis is severe enough to keep you from performing activities commonly required for working. These activities include:
- Sitting or standing;
- Kneeling or walking;
- Lifting; and
- Using fine motor skills.
Based on your limitations, you may be deemed capable of heavy, medium, light, or sedentary work.
Medical Evidence Proving Osteoarthritis
To prove the extent of your disability from osteoarthritis, you will likely need doctor and hospital records, medical imaging studies, laboratory test results, and, sometimes, a questionnaire that should be completed by your doctor. Your provider also may use information from the Arthritis Foundation when evaluating your arthritis claim. In general, the records must include the following:
- A confirmed diagnosis of osteoarthritis;
- A doctor’s note detailing the frequency and severity of your symptoms and how they limit your ability to function at home or in the workplace;
- Imaging (X-rays, CT Scans, MRI’s) that shows degeneration in the joints or bone; and
- A history of any treatments tried.
Evaluating Disability for Persons With Osteoarthritis
The insurance company’s adjudicator is the insurance adjuster assigned to your claim. The adjuster may have your file reviewed by a physician, psychologist, or another medical disability examiner (such as a nurse practitioner) to give an opinion as to your level of impairment. The adjuster may also send you for a compulsory medical examination or functional capacity evaluation. In evaluating disability for persons with osteoarthritis, the insurance adjuster should consider all of the available evidence, including the clinical course from the onset of the illness, and should consider the impact of the illness on each affected body system.
If the insurance adjuster believes there is not enough information to make a decision, he or she may call or write you to find out if you have the needed information. If you do not, they may ask you or, in some circumstances, an independent medical source, to provide the information.
Although your physician may reach a diagnosis of osteoarthritis on the basis of your symptomatology, your disabling impairment should still be documented by medically-acceptable clinical and laboratory findings. Statements merely recounting your symptoms or providing only a diagnosis will not usually be sufficient to be approved for long-term disability insurance benefits. The insurance company should have reports documenting your objective clinical and laboratory findings. Thus, it is essential that your doctor(s) submit all objective findings available concerning your condition, even if they relate to another disorder or establish that you have a different condition.
How the Insurance Company Assesses Your Residual Functional Capacity (RFC)
In light of your documented symptoms, the insurance company may develop an RFC for you that states, for example, that due to persistent pain or stiffness, you need to take frequent breaks throughout the day to rest as needed. Because most employers would not accommodate this limitation, it would be difficult for you to obtain and maintain most jobs.
For those who specifically suffer from osteoarthritis in the lower extremities, walking, climbing, lifting, or squatting may be difficult or almost impossible. An RFC, in this case, may limit someone suffering from lower extremity osteoarthritis to sedentary or desk work only. If one’s osteoarthritis causes severe pain when sitting too long, or staying in one position, it may be found that sedentary work is also not an option.
On the other hand, people who suffer from osteoarthritis in the upper extremities may have trouble using their hands, shoulders, and arms, which would make it difficult to perform most tasks in the workplace including reaching, grabbing, writing, or typing. It may not be possible to perform any job when suffering from osteoarthritis in the upper extremities.
Living with chronic pain from arthritis can also cause mental health problems such as depression or anxiety. One may also experience cognitive impairment due to the use of pain-relieving medication that may be prescribed to the patient. If you are receiving mental health treatment or if you are under the care of a pain management doctor (or taking a prescription that impairs your cognition), you should ask your treating physician (your psychiatrist or psychologist) to fill out a mental RFC form that details his or her opinions of your work-related limitations. Keep in mind that the insurance company will assign them weight only if they are supported by objective medical evidence.
Work with an Experienced Long Term Disability Insurance Attorney to Ensure You Get the Benefits You Deserve
Your best chance of having a long term disability case approved because of osteoarthritis comes by working with an experienced long term disability lawyer. 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.
Your long term disability attorney will be familiar with how insurance providers handle osteoarthritis claims and will help you prepare your application and collect essential evidence. It’s important to note that your long term disability attorney does not get paid until you do, so you can proceed with your case without fear of upfront legal bills or costs.
If your LTD claim has been wrongfully denied or terminated and you’d like to speak to an experienced long term disability insurance attorney about your disability relating to osteoarthritis and how it may be impacting your ability to work, contact us at (888) 321-8131 to schedule a consultation.