Kidney Failure and Long-Term Disability Insurance Claims

Patients with kidney disease may be unable to work because of their disease and its related complications. Patients who cannot work because of their kidney disease 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 Kidney Failure?

Kidney failure is a “genitourinary” impairment. You may qualify for LTD benefits with severe kidney disease, which may be evidenced by the following:

• The need for regular dialysis;
• A kidney transplant;
• Reduced glomerular filtration combined with symptoms of damage;
• Nephrotic syndrome, or
• Severe complications of kidney disease.

Each of these situations will be discussed below. If you do not have any of the above problems, yet you still cannot work due to kidney failure, you can still qualify for long-term disability benefits if you can show the insurance company that your condition causes such significant limitations that it keeps you from working.

Chronic Kidney Disease

Poor kidney function can be caused by a chronic disease and may be evidenced by one of the following:

• Ongoing peritoneal dialysis (a method of hemodialysis that involves dialyzing solution being put into and removed from the peritoneal cavity intermittently or continuously);
• Ongoing hemodialysis (the removal of toxins from the blood with an artificial kidney machine);
• Kidney transplantation; or
• Reduced glomerular filtration.

Reduced glomerular filtration may be shown by persistently high levels of serum creatinine (a natural product of muscle metabolism), low creatinine clearance levels, or a low estimated glomerular filtration rate (eGFR). To qualify by showing reduced glomerular filtration, you may also want to show that you suffer from one or more of the following:

• Renal bone degradation and bone pain;
• Peripheral neuropathy (which may cause an inability to filter toxic substances from the blood) or
• Despite taking medication, fluid overload syndrome is documented by diastolic hypertension, signs of vascular congestion or anasarca (massive edema or swelling), or anorexia with weight loss and a BMI of 18.0 or less.

Nephrotic Syndrome

Some kidney diseases are evidenced by excess protein in the urine (proteinuria) and swelling (edema) of varying levels. Low serum albumin (hypoalbuminemia) and hyperlipidemia (high cholesterol) are sometimes present. To be approved for disability benefits due to nephrotic syndrome, you would likely need to show that you have had extreme edema for at least three months plus either (1) low serum albumin levels with either moderately high levels of protein in the urine or a total-protein-to-creatine ratio of 3.5 or greater, or (2) very high levels of protein in the urine.

Complications of Chronic Kidney Disease

You may qualify for long-term disability benefits if you’ve experienced severe complications due to kidney disease. For example, some individuals with kidney disease also suffer from congestive heart failure, stroke, hypertensive crisis, or acute kidney failure requiring hemodialysis.

How Does a Long-Term Disability Insurance Company Evaluate Kidney Disease?

What type of evidence does a long-term disability insurance company use to evaluate a claim for chronic renal disease? The adjuster handling your claim will want to see a longitudinal medical history that includes a record of all hospitalizations, medical treatment notes from your treating physician or physicians, and laboratory findings that document progressive renal disease. Also, clinical or lab evidence showing a deterioration in kidney function is essential. An example is a lab report showing an elevation of serum creatinine or proteinuria.

Additionally, the insurance company likes to obtain and review current clinical observations and treatment notes. If the claimant is undergoing dialysis, there should be laboratory findings that document the claimant’s renal function before the start of dialysis for comparison and a doctor’s statement as to the need for ongoing dialysis.

If an individual has been diagnosed with nephrotic syndrome, the medical record should evidence the extent of edema, including presacral, pretibial, and periorbital edema. Additionally, medical evidence should document any instances of ascites, pericardial effusion, or pleural effusion. Finally, the records should include serum albumin and proteinuria levels.

Finally, if a renal biopsy is performed, medical evidence should include the microscopic examination of the specimen report. Suppose the actual microscopic examination report is not available. In that case, the insurance company may accept a doctor’s statement indicating a biopsy was performed and a description of the results.

Benefits for Claimants with a Kidney Transplant

There is a recovery period after a kidney transplant when most insurance companies agree that the claimant cannot work. However, after six to twelve months, the insurance company will likely want to evaluate ongoing disability eligibility based on the claimant’s residual impairments.

When the insurance company determines whether an individual has had medical improvement post-transplantation, the adjuster assigned to your claim will consider things like kidney rejection episodes, renal infection frequency, negative side effects of immunosuppressants and corticosteroid treatment, other systemic infections, neuropathy, or other organ system deterioration. When making a medical improvement determination, the insurance company will also consider whether the claimant has had an absence of symptoms, signs, or laboratory findings indicative of kidney failure.

Disability Based on Functional Limitations

In evaluating a claim for kidney disease, the insurance company will consider the effect of the disease on your abilities. The adjuster handling your claim will look at your symptoms and decide how they limit your ability to work. If the doctor has included a detailed opinion about how the disease limits the patient’s ability to work, the LTD insurance company should consider that. The insurance company will come up with a “residual functional capacity” (RFC) rating based on the type of work it thinks you can do (sedentary work, light work, medium work, or heavy work).

Some patients with kidney failure or nephrotic disease also suffer from extreme bone pain, fatigue caused by anemia, shortness of breath, trouble with exertion, or swelling of the knees or feet. These symptoms can cause problems with walking or standing for long periods, which may result in the issuance of an RFC for no more than sedentary work. In assessing your RFC, the insurance company also considers factors like the side effects of therapy and medication, the effects of any post-therapeutic residuals, and the expected duration of treatment.

The insurance company will use your RFC to determine whether there are any types of jobs you can do. For example, you may be approved when you are given an RFC of sedentary work, and you cannot sustain work at a productive pace for 2-hour intervals because of fatigue, anemia, and bone pain caused by your kidney disease.

Get Help with Your Long-Term Disability Claim

If you are unable to work as a result of kidney failure, 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 they deserve. We handle claims with New York Life, Lincoln Financial, Reliance Standard, Prudential, The Hartford, The Standard, MetLife, Guardian, Unum, Sun Life, and other major disability insurance companies. If your kidney failure 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. Call us today to discuss your claim at (888) 321-8131.