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Benefit Limitations In Long-Term Disability Claims For Musculoskeletal Disorders

Disability insurance can be a crucial lifeline for individuals who cannot work due to severe health conditions. One of the common health issues that lead to long-term disability claims is musculoskeletal disorders (MSDs). The impairments caused by these conditions are real and can significantly impact the ability to work. However, individuals filing claims for these conditions often face significant challenges, from policy limitations to wrongful denials.

Understanding Musculoskeletal Disorders

Musculoskeletal disorders encompass various injuries and illnesses affecting the body’s musculoskeletal system, which includes bones, joints, muscles, ligaments, tendons, nerves, discs, and blood vessels. Musculoskeletal disorders include a range of localized conditions and systemic diseases such as:

Depending on the severity, these conditions can dramatically affect a claimant’s mobility, strength, and flexibility. These symptoms and limitations impact a person’s overall capacity to perform daily tasks, including work-related activities.

Long-Term Disability Claims for Musculoskeletal Disorders

Submitting a long-term disability claim is more than just stating that you have a disorder that prevents you from working. Insurance companies require substantial medical evidence demonstrating how the disorder limits your ability to work and necessitates disability benefits. To substantiate your claim, it is crucial to provide extensive medical documentation. This documentation can include imaging studies, physical examination findings, physician notes, lab results, and evidence of treatments tried and their outcomes. This evidence should be clear and detailed enough to demonstrate how your condition impairs your ability to work.

Musculoskeletal Disorder Limitations in Long-Term Disability Claims

Insurance policy limitations may sometimes apply when filing a long-term disability claim based on a musculoskeletal condition. Insurance policies frequently include clauses that limit the benefits payable for “subjective” conditions. These are conditions based primarily on patient self-report rather than objective evidence.

Unfortunately, many MSDs can fall into this category. This is especially true when most evidence involves patient-reported pain or fatigue levels. Some policies might only pay benefits for such conditions for a limited duration (e.g., 24 months).

There may also be limitations specific to MSDs in your policy. Here is an example from one such policy:

“Payment of long term disability benefits is limited to 24 months during your entire lifetime for a Disability caused or contributed to by musculoskeletal or connective tissue disorders including, but not limited to:

  • Any disease or disorder of the cervical, thoracic, or lumbosacral back and its surrounding soft tissue.
  • Sprains or strains of joints or muscles.
  • Carpal tunnel or repetitive motion syndrome.
  • Temporomandibular joint or craniomandibular joint disorder
  • Myofascial pain.

This limitation will not apply to:

  • Herniated discs with neurological abnormalities that are documented by electromyogram, and computerized tomography or magnetic resonance imaging.
  • Tumors, malignancies, or vascular malformations.
  • Radiculopathies that are documented by electromyogram.
  • Spondylolisthesis, grade II or higher.
  • Myelopathies and myelitis.
  • Traumatic spinal cord necrosis.
  • Rheumatoid or psoriatic arthritis.”

Other policies may be less specific, stating that payment of long-term disability benefits for a “neuromuscular, musculoskeletal or soft tissue condition” is limited to a lifetime maximum of 24 months.

Understanding the specific terms and conditions of your disability insurance policy is vital to navigating these limitations. For example, if you suffer from a condition like arachnoiditis that originates in the nervous system, the limitation may not apply. Moreover, working with medical professionals who understand these nuances can help present the most substantial evidence to support your claim.

Wrongful Denials of Disability Claims for Musculoskeletal Disorders

While it’s not uncommon for initial disability claims to be denied, there can be cases where such denials are inappropriate. Insurance companies may downplay the severity of a disabling condition and argue that the claimant can still perform some work. Another reason commonly cited in denial letters is a lack of objective evidence.

Sometimes, a claim will be approved initially but then terminated prematurely. A wrongful termination could also be due to various factors, from misinterpreting policy terms to disregarding medical records.

However, a wrongful claim denial or termination can be challenged. If you feel your disability claim has been wrongfully denied, it’s essential to consult with a lawyer specializing in disability claims. An experienced long-term disability attorney can evaluate your case and guide you through the appeal process.

Get Help with Your Musculoskeletal Disorder Claim

Musculoskeletal disorders can significantly limit a person’s ability to work and warrant filing a long-term disability claim. However, when filing such claims, it’s essential to be aware of the potential pitfalls, from policy limitations to wrongful denials. If faced with a wrongful long-term disability denial, remember you have the right to seek legal counsel and file an appeal. The journey to receiving LTD benefits may be complex, but you don’t have to walk it alone. Call Ortiz Law Firm today at (888) 321-8131 to schedule a free case evaluation with an experienced disability insurance attorney.