When Disability Insurers Deny Long COVID Claims Due to Mental Health Limitations and Objective Evidence Requirements

Long COVID has left millions of people struggling with debilitating symptoms that disrupt every facet of their lives. Despite its recognized impact, disability insurance companies often attempt to deny claims by misclassifying the condition to trigger a mental or nervous limitation or citing a lack of objective diagnostic evidence. Claimants are labeled with Somatic Symptom Disorder or similar psychiatric conditions when there is clear evidence of physical impairment, or claims are denied on the grounds that disabling conditions like Long COVID lack definitive laboratory tests. These denials are not only unfair, but often violate established legal precedent.

Understanding Long COVID and Its Challenges

According to the National Academies of Sciences, Engineering, and Medicine, Long COVID manifests in a variety of ways, ranging from fatigue and post-exertional malaise to cognitive impairment and neurological problems. Diagnosing Long COVID is challenging due to the lack of definitive biomarkers, leaving patients vulnerable to skepticism from insurers and healthcare providers alike.

Long COVID can exacerbate pre-existing health conditions or present as new conditions, including:

• Cognitive Impairment: Often referred to as “brain fog,” patients experience difficulty concentrating, memory lapses, and reduced cognitive function, which can severely impact work performance.
• Migraine and Chronic Headaches: Many patients report recurrent, severe headaches that interfere with daily functioning and increase fatigue.
• Postural Orthostatic Tachycardia Syndrome (POTS) and Dysautonomia: Dysregulation of the autonomic nervous system can cause rapid heart rate, dizziness, and fainting on standing, significantly affecting mobility and independence.
• Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Profound and persistent fatigue that worsens with physical or mental exertion, often associated with sleep disturbances and muscle pain.
• Mast-Cell Activation Syndrome: Dysregulation of the immune system that can cause allergic-like reactions, swelling, and gastrointestinal distress.
• Fibromyalgia: Chronic pain and tenderness throughout the body, often accompanied by fatigue and sleep disturbances.
• Connective-Tissue Diseases: Conditions such as lupus or rheumatoid arthritis can be aggravated or triggered by Long COVID, resulting in joint pain and systemic inflammation.
• Autoimmune Disorders: New or worsening autoimmune diseases, such as Sjögren’s syndrome, may occur, causing widespread systemic effects.
• Peripheral Nervous System Disorders: Damage to the peripheral nerves can cause numbness, tingling, or weakness, significantly affecting mobility and function.
• Guillain–Barré Syndrome: In this rare disorder, which can follow viral infections such as COVID-19, attacks the nerves, causing muscle weakness and, in severe cases, paralysis.
• Functional Neurological Disorder (FND): A condition in which patients experience neurological symptoms, such as weakness, seizures, or sensory loss, that are not due to structural damage but are still debilitating.
• Cavernous Malformation: A vascular disorder characterized by abnormal blood vessels in the brain or spinal cord that can cause headaches, seizures, and neurological deficits.
• Central Sensitization Syndrome: A chronic pain condition caused by increased sensitivity of the central nervous system, often resulting in widespread pain and fatigue.

The breadth of these conditions illustrates the complexity of Long COVID and underscores the need for comprehensive medical evaluations and appropriate disability accommodations.

The Tactics Insurers Use to Deny Claims

Insurance companies often rely on a variety of tactics to deny Long COVID disability claims. Understanding these strategies can help claimants prepare stronger appeals.

• Delays in Processing Claims: Insurers may slow down the claims process by repeatedly requesting additional documentation or conducting excessive investigations, hoping claimants will give up in frustration.
• Excessive Documentation Requests: By demanding exhaustive records or new test results that may not exist for Long COVID, insurers place an undue burden on claimants to prove their case.
• Reliance on Biased Medical Reviewers: Insurers often use independent medical examiners (IMEs) or file reviewers who lack experience with Long COVID or who consistently side with the insurer’s denial rationale.
• Overuse of Mental Illness Limitations: Claimants may find that their physical symptoms are dismissed as psychiatric conditions, triggering restrictive policy clauses that limit benefits for mental health claims.

Understanding these tactics is critical for claimants to thoroughly document their cases and consult with legal professionals when necessary.

Why There Is So Much Confusion About Long COVID

The confusion surrounding Long COVID often stems from a lack of understanding among healthcare providers and insurers. One recurring question is whether Long COVID qualifies as a somatoform disorder, such as Somatic Symptom Disorder (SSD).

Insurers often argue that Long COVID symptoms are exaggerated or primarily psychiatric, based on the subjective nature of patient complaints. However, this perspective is both scientifically flawed and legally contested.

• The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines SSD as a condition in which patients exhibit disproportionate concern about physical symptoms, regardless of whether those symptoms are medically explained. However, the DSM-5 also recognizes that SSD can coexist with legitimate medical conditions. This recognition is critical for claimants with Long COVID because their symptoms often arise from clear physiological processes, even when traditional diagnostic tests are inconclusive.
• Patients with Long COVID also face stigma and dismissal, as highlighted by Dr. Yochai Re’em in Psychology Today. Dr. Re’em noted that healthcare providers often misinterpret patients’ concerns as disproportionate due to a lack of familiarity with the breadth of the condition. Such misinterpretations can lead to unfair denials of disability benefits.
• Historical context also reveals the risks of misdiagnosis. The DSM-IV previously cautioned against rigid distinctions between mental and physical disorders, noting the interconnectedness of these domains. While the DSM-5 no longer includes this language, it does warn that forensic misuse of diagnostic criteria can lead to inappropriate conclusions in legal and insurance contexts.

The systemic misunderstanding of Long COVID underscores the importance of patient advocacy and accurate medical documentation to counter biased assumptions and ensure fair treatment.

Relevant Rulings

Although Long Covid and the absence of objective test results often lead to the misclassification of a medical condition as a psychiatric impairment or could result in a denial of benefits altogether, courts have consistently rejected attempts to misclassify physical conditions as psychiatric in nature. Legal precedent has consistently challenged insurers’ attempts to misclassify or deny claims involving complex medical conditions. Notable cases include:

• Mitchell v. Eastman Kodak Company:The court emphasized that it is inappropriate to require “clinical evidence of etiology” for conditions such as Chronic Fatigue Syndrome (CFS), for which, like Long Covid, “there is no ‘dipstick’ laboratory test.”

• Sobel v. Sun Life & Health Insurance Company: In this case, the court considered whether a claimant’s chronic fatigue syndrome (CFS) was improperly classified as depression. The court ultimately ordered Sun Life to obtain further testing to determine the correct diagnosis, underscoring the need for thorough evaluations when objective tests are not available.
• Watson v. Reliance Standard Life Insurance Company: The court held that the claimant’s disability was due to a physical condition (CFS), not depression. This case affirmed that insurers cannot simply dismiss legitimate medical diagnoses by substituting behavioral health classifications.
• McEachin v. Reliance Standard Life Insurance Company: This case reaffirmed that disability insurance policies’ mental health limitations do not apply when a claimant’s physical condition independently causes disability. Psychiatric diagnoses are irrelevant when physical impairments render the claimant disabled.

These rulings underscore the judiciary’s recognition of the nuanced interplay between physical and mental health in disability claims and the need for insurers to evaluate claims comprehensively.

Appealing Denials and Protecting Your Rights

As Long COVID continues to challenge conventional definitions of illness and disability, claimants must remain vigilant against unfair denial practices. To strengthen their case, claimants should:

• Maintain detailed medical records, including statements from treating physicians linking symptoms to physical conditions.
• Emphasize any supporting case law or medical guidelines.
• Consult experienced disability attorneys to navigate complex ERISA appeals and insurer tactics.

Attorneys play a critical role in leveling the playing field, ensuring that insurers meet their obligations and provide the benefits their clients rightfully deserve. Securing legal representation early in the appeals process can make a significant difference in the outcome. Here’s why:

• Navigating Complex ERISA Requirements: ERISA disability claims have strict deadlines and procedures. Missing a deadline or failing to exhaust administrative remedies can jeopardize a case. Legal counsel ensures that these requirements are met.
• Building a Strong Record for Appeal: An attorney can help gather detailed medical evidence, expert testimony, and relevant precedent to create a strong administrative record that is essential for appeal or litigation.
• Challenging Biased Reviews: Insurers often rely on medical reviewers who favor denials. Legal representation ensures that these reviews are effectively challenged with rebuttal arguments supported by treating physician testimony.

As Long COVID continues to challenge conventional definitions of illness and disability, claimants must remain vigilant against unfair denial practices. Attorneys play a critical role in leveling the playing field, ensuring that insurers live up to their obligations and provide the benefits their clients rightfully deserve. By seeking legal counsel early, claimants improve their chances of navigating the appeals process smoothly and securing the benefits they deserve.

Get Comprehensive Support for Your Long-Term Disability Claim

With over 20 years of experience handling thousands of long-term disability cases for a wide range of medical conditions, Nick Ortiz and our dedicated team offer specialized guidance to maximize your chances of success.  Here’s what you get when you work with the Ortiz Law Firm:

Dedicated Team and Direct Communication

• A dedicated paralegal and legal assistant assigned to your case.
• Custom email access to communicate with our team and submit information directly to your file.
• Client portal for convenient, 24/7 case status updates.
• Contact us by phone, text, email, or fax, whichever is most convenient for you.

In-Depth Claim File Analysis

• We request and analyze the complete claim file, which includes everything related to your case, often over 1,000 pages of documents, medical records, and correspondence.
• We meticulously review every detail to understand the insurer’s reasoning and identify gaps in the file that we can fill in to support your case.

Comprehensive Medical Evidence Collection

• Simultaneous Medical Record Requests: While waiting for the claim file, we immediately request updated medical records from all of your doctors to ensure we have a complete, up-to-date picture of your health.
• Customized Residual Functional Capacity (RFC) Forms: We work with your doctors to create custom RFC forms tailored to your specific medical conditions, which outline your limitations in far greater detail than standard forms.
• Doctor Opinion Evidence: We obtain specific opinions from your doctors detailing your work restrictions in language that speaks directly to your claim.

Policy and Vocational Analysis

• We dissect your insurance policy to understand the specific definitions of “disability” and “occupation” as they apply to your case, so that we can frame our appeal within the terms of the policy.
• If necessary, we will retain vocational experts to evaluate any unrealistic job recommendations made by the insurer and show why you cannot perform the suggested roles.

Detailed Personal Affidavit Preparation

• Using a tailored questionnaire, we prepare an affidavit—your sworn statement under penalty of perjury—that describes your day-to-day limitations from your own perspective and adds weight to your appeal.

Strategic Legal Analysis

• Our appeals go beyond basic arguments; we perform a comprehensive legal analysis, breaking down every mistake the insurer made in denying your claim.
• We prepare a detailed appeal document, typically 14-20 pages in length, summarizing all medical, vocational, and legal elements to present a compelling case for overturning the denial.

This meticulous approach allows us to fully develop your case and ensure that nothing is overlooked. And with our “no win, no fee” model, you only pay if we successfully recover your benefits. If you’re facing a denied Long COVID disability claim, our firm is here to advocate for you. Contact us online or call (888) 321-8131 to schedule a free case evaluation today.