Understanding the Difference Between Diagnosis and Functional Impairment in Long Term Disability Claims

When it comes to filing for long term disability (LTD) benefits, many people assume that a medical diagnosis is the golden ticket to approval. While a diagnosis is an essential part of the process, it is by no means the only criterion that insurers or adjudicators consider. Understanding the nuanced difference between diagnosis and functional impairment can significantly impact the outcome of your LTD claim. 

The Importance of Diagnosis

The diagnosis is the starting point in any disability claim. When a medical professional identifies a specific condition or illness you have, it sets the stage for determining how that condition might limit your abilities. Diagnoses are based on a comprehensive review of symptoms, medical history, and diagnostic tests, often involving imaging studies, lab tests, or other evaluations. 

However, a diagnosis is not always straightforward, and sometimes, claimants may have multiple coexisting diagnoses, each contributing to the overall picture of disability. A diagnosis provides a critical framework, but it is not the end of the investigation. Instead, it’s the first step in understanding how the diagnosed condition(s) affect your ability to function. 

Delving into Functional Impairment

Functional impairment refers to how a condition—or multiple conditions—affect your ability to carry out essential tasks in your daily life or job functions. While a diagnosis identifies a medical issue, functional impairment describes the practical implications of living with that diagnosis. 

When evaluating long term disability claims, adjudicators look at: 

1. Activities of Daily Living (ADLs): How does the diagnosis impact tasks like bathing, eating, dressing, toileting, and moving around? 

1. Work-Related Tasks: Does the diagnosis interfere with your ability to perform tasks specific to your job, such as sitting for extended periods, lifting heavy objects, or operating machinery? 

1. Cognitive Functions: Are you experiencing memory loss, reduced attention span, or other cognitive impairments that affect your performance at work? 

1. Pain Levels and Fatigue: These subjective experiences can profoundly affect functional capabilities, even if they are difficult to quantify. 

1. Intermittent Symptoms: Some conditions have symptoms that come and go, like migraines or flare-ups of autoimmune diseases. Adjudicators consider the frequency and severity of these episodes. 

1. Combined Effects: In cases of multiple diagnoses, the review assesses how these conditions interact to create a more complex picture of functional impairment. 

Assessing Functional Impairment: The Tools 

Several tools can assess functional impairment, often involving: 

1. Functional Capacity Evaluations (FCEs): These are sets of tests that measure physical and cognitive abilities. 

1. Doctor’s Notes and Medical Records: These documents can provide insights into the limitations and restrictions faced by the claimant. 

1. A Residual Functional Capacity form, or Medical Source Statement form: This is an excellent way for the claimant’s doctor to summarize the claimant’s diagnoses, the severity of those diagnoses, and the claimant’s various restrictions and limitations that result from those diagnoses. These forms can be customized to the claimant’s individual claim. 

1. Personal Journals or Logs: These can help show how symptoms and limitations affect daily life. 

1. Witness Testimonies: Spouses, family, or colleagues can offer valuable insights into a claimant’s everyday challenges. 

The Intersection and Importance 

The intersection of diagnosis and functional impairment forms the crux of a long term disability claim. While a diagnosis might suggest a theoretical limitation, the functional impairment demonstrates the actual, real-world restrictions and challenges faced by the claimant. 

Moreover, understanding this interplay is crucial for both claimants and those involved in the adjudication process. For claimants, understanding the importance of functional impairment can help them be more proactive in documenting their experiences and limitations. For adjudicators, this understanding ensures a more comprehensive review, thereby providing a more accurate and fair assessment. 

The Difference Between Diagnosis and Functional Impairment 

Here is an example of how your treating physician might describe both your diagnosis and resulting functional impairment: 

Suzie Q has multiple disc herniations in her lower back – specifically at L3-L4 and L4-L5. As a result of these herniations, she should not lift and carry more than 5 pounds of weight. She should restrict bending, stooping, and crawling. She cannot stand for more than 10 minutes at a time or for longer than one hour in total during an eight-hour period. She cannot walk for more than 10 minutes at a time or for longer than 30 minutes in total during an eight-hour period. She would have difficulty sitting for longer than 20 minutes at a time or for more than three hours in total during an eight-hour period. The remainder of the time she would need to lie down or recline in a recliner with her feet elevated. 

In this example, Suzie Q has been diagnosed with disc herniations at L3-L4 and L4-L5. However, this diagnosis does not demonstrate how her symptoms affect her day-to-day life. Suzie’s functional impairment is demonstrated by her physician’s description of her limitations. 

Conclusion 

In summary, while a diagnosis is an essential element of a long term disability claim, it is just one part of a multifaceted evaluation. The assessment of how a claimant is functionally impaired by their diagnoses is an equally vital component. Functional impairments paint a more complete picture, allowing for a more nuanced understanding and, ultimately, a fairer and more accurate claim evaluation. 

Understanding the difference between diagnosis and functional impairment is a vital first step in navigating the complexities of long term disability claims. However, knowledge alone may not be sufficient to secure the benefits you deserve. Expert guidance can make a crucial difference in the outcome of your claim. 

If you’re faced with a long term disability claim denial, don’t leave your future to chance. Call Ortiz Law Firm for a free case evaluation with a long term disability attorney. We can provide you with personalized advice tailored to your unique situation and help you gather the evidence needed to support both the diagnosis and the functional impairment aspects of your case. 

Don’t wait. Your well-being is too important to risk going it alone. Call today for your free case evaluation and take the first step toward securing the benefits you rightfully deserve.