Patients with a traumatic brain injury may be unable to work because of their disease and its related complications. Patients who find themselves unable to work because of their traumatic brain injury 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 a Traumatic Brain Injury?
Traumatic brain injury (TBI), which is also called intracranial injury, is an acute injury to the brain caused by a traumatic event or external force such as a car accident, military incident, slip/trip/fall, or discharge from a firearm. The general term “head injury” is often used synonymously with traumatic brain injury. A TBI can vary in severity from mild temporary amnesia to a more serious permanent coma. Some TBIs may heal over time and some functionality may improve through therapy; however, other impairments may never improve — or may even worsen over time.
LTD Disability Benefits for TBI
Severe TBIs may qualify for long-term disability (LTD) insurance benefits after taking into account the wide range of impairments that a TBI may cause. Cerebral trauma may cause numerous impairments that would limit work activity, including seizure disorders and strokes.
TBI symptoms can vary widely depending on the type and severity of the injury and the area of the brain affected by the trauma. Immediately after an injury, a patient may lose consciousness for a period of time from a few seconds to a few minutes. Debilitating symptoms of TBI may include severe headaches, nausea and vomiting, dizziness, fatigue, tired eyes, blurred vision, lightheadedness and lack of motor skills or motor control (use of the hands, arms, legs, and feet).
If your symptoms are so severe that you are no longer able to work, you may qualify for LTD benefits for cerebral trauma.
Epilepsy
To qualify for long-term disability benefits due to epilepsy (or non-epileptic seizure disorders), you must show that your seizures and the recovery periods after a seizure are so frequent and debilitating that you cannot continue full-time employment. Your doctor should describe a typical seizure, indicate how much of the description is based on personal observations versus others’ observations, and describe your recovery period after each seizure event (i.e., how much time you will need to recover from each seizure, how fatigued or drained you are after each seizure, etc.). For more information about LTD benefits for epilepsy, see our article on qualifying for long-term disability insurance benefits for epilepsy.
Central Nervous System Vascular Accident
If you have had a stroke (or multiple strokes), you may qualify for LTD due to said central nervous system vascular accident(s). You are most likely to qualify for benefits when you continue to experience the following types of impairments after the stroke(s):
- Trouble with language skills resulting in ineffective speech or communication, or
- Significant and persistent disruption of the use of your arms or legs that interferes with your ability to walk and/or ability to use your fingers, hands, and arms.
For more information, see our article on qualifying for LTD benefits for stroke.
Organic Mental Disorders
To qualify for long-term disability insurance benefits due to organic mental disorders (cognitive or emotional changes resulting from brain damage), you should be able to prove the following types of impairments:
- A change in your cognitive abilities;
- Disorientation;
- Personality changes; or
- Mood changes that limit your daily activities, social functioning, or the ability to concentrate.
You can also demonstrate these types of impairments where, for example, your IQ is 15 points less than before your accident, or if your IQ is within the severely impaired range on neuropsychological testing.
Diagnosis of a TBI
Diagnosis of a traumatic brain injury is based on clinical evidence and lesion occurrences. Neurological examination is usually performed to verify whether the pupils are contracting normally in response to light. In emergency situations, such as immediately after an accident, a radiological test known as computed tomography is widely used to provide a fast and accurate diagnosis. Other objective medical procedures, including MRIs, CT scans, and X-Rays, can be performed at a later time to verify the extent and location of injuries. In addition, a neuropsychological examination can be performed to assess the lasting cognitive impairments and to assist in planning rehabilitation.
The Long-Term Disability Insurance Company’s Review of Your Claim
In evaluating a claim for LTD benefits, the adjuster assigned to your claim will evaluate the impact of your TBI on your ability to perform work activities. The insurance company may assess your physical, mental, and sensory limitations using an Attending Physician Statement (APS) – also called a residual functional capacity (RFC) form – that it will ask your physician to fill out. This APS form should note the limitations that you have as a result of your TBI that affect your ability to work. The processing of disability claims is focused heavily on a claimant’s measurable limitations and objective findings showing impaired functional ability.
For those who have suffered a TBI, there is often a distinct change in mental and/or physical functions that can prevent them from returning to a previous job. Under most policies, the standard is whether the claimant can return to his or her prior work for the first two years after the disability. However, it is important to note that most policies change the definition of disability after 24 months to evaluate whether the claimant can return to virtually any job.
When filing for long-term disability insurance benefits on the basis of a traumatic brain injury diagnosis, it is imperative that you present all appropriate medical evidence, including detailed reports of functional restrictions imposed by the symptoms of your condition over time.
TBIs are different than many other illnesses or diseases in that it can be difficult to make a long-term prognosis about an individual’s recovery and job abilities. Insurance companies are acutely aware of the high variability associated with TBIs. With TBIs, an individual who sustains profound neurological impairment will be constantly reassessed to determine whether the claimant’s neurological or mental impairments continue to be severe and debilitating.
Your Traumatic Brain Injury Disability Case
If you can no longer work because of traumatic brain injury and you have a long-term disability insurance policy, you should qualify for LTD benefits. It is important to be aware that the extent of your impairment will be determined based largely on the type, duration, frequency, and debilitating effect of symptoms of your TBI rather than a diagnosis alone. Your doctor should indicate where the doctor’s treatment and observations corroborate the negative effects and exertional limitations described in your claim.
If you are not currently represented by a long-term disability attorney, you should seriously consider hiring an attorney to represent you in the appeal process. Nick Ortiz is an experienced long-term disability lawyer and he offers free consultations to claimants when a TBI long-term disability claim has been denied, unreasonably delayed, or terminated. Call (888) 321-8131 to discuss your rights.
