Filing a long-term disability (LTD) claim involves more than just filling out forms—it requires comprehensive medical documentation that meets your insurance company’s standards. To qualify for benefits, you must provide clear, convincing evidence that your physical or mental condition prevents you from working. This guide breaks down the medical requirements insurers look for, including objective evidence, residual functional capacity forms, and more.
Proving Your Disability
The longest and most tedious part of the long-term disability claim process is gathering medical evidence to prove your disability. You will need to provide the claim adjuster with proof of your disability. This includes the opinion and notes from your treating physician(s), all lab and test results, x-rays, MRI scans, notes from doctors who have treated you, and detailed surgical reports. You need to gather evidence from all of the doctors treating you for your disability, not just your primary physician.
Objective Evidence To Support a Long-Term Disability Claim
Most insurance policies require proof of objective evidence before the insurance company pays out benefits on an LTD claim. This is the evidence that insurance companies cannot deny exists. Objective medical evidence includes medical signs and laboratory findings:
- Medical signs are anatomical, physiological, or psychological abnormalities that a medical provider can observe. Signs are separate from the claimant’s statements (often called “subjective complaints” or symptoms). Medically acceptable clinical diagnostic techniques may show signs. Psychiatric signs are medically demonstrable phenomena that indicate specific psychological abnormalities, e.g., abnormalities of behavior, mood, thought, memory, orientation, development, or perception. They must also be shown by observable facts that can be medically described and evaluated.
- Laboratory findings are anatomical, physiological, or psychological phenomena that can be shown using medically acceptable laboratory diagnostic techniques. Some of these diagnostic techniques include chemical tests, electrophysiological studies (electrocardiogram, electroencephalogram, etc.), X-rays, MRIs, CT scans, blood tests, and psychological tests.
A functional capacity evaluation (FCE) can also provide objective clinical evidence to prove whether the claimant is physically capable of performing the usual and customary duties of a given occupation. Psychological and neuropsychological testing are objective tools that may be used to dispute the insurance company’s position that the claimant is malingering or exaggerating.
Why Objective Evidence Is Needed
Objective evidence is crucial for long-term disability claims because it provides concrete proof of the claimant’s condition and limitations. Without solid evidence, it’s just one person’s word against another. Having medical records, test results, and assessments from healthcare professionals can strengthen the case and make it more convincing.
Objective evidence clearly shows the claimant’s situation, leaving little room for doubt or interpretation. This can ultimately lead to a smoother and more successful claims process, ensuring that individuals receive the support they genuinely need during challenging times.
All of the foregoing evidence is especially important in proving disabilities that are ordinarily diagnosed based on the claimant’s subjective complaints, such as fibromyalgia, chronic pain disorders, chronic fatigue syndrome, and back pain conditions.
What If Objective Evidence Is Not Available?
When conclusive objective evidence is unavailable, a long-term disability may still be validated through the use of subjective evidence. Subjective evidence primarily includes the patient’s self-reports and the observations of friends and family.
RELATED POST: Objective vs. Subjective Evidence in LTD Claims
If your doctor will provide a statement supporting your long-term disability claim, you should obtain a written medical source statement. Be aware, however, that overly conclusory statements are nearly useless. For example, a letterthat essentially say, “My patient is 100% disabled and unable to work” will not win your claim. The claims examiners who review LTD claims are not interested in short, conclusory statements from personal physicians.
Instead, the doctor should explain why the claimant is unable to work. How can a treating physician do this? In a “to whom it may concern” letter or by filling out a residual functional capacity form. The LTD insurance company is looking for a doctor’s evaluation of how well the disability claimant can:
- Lift and carry weight;
- Sit;
- Stand;
- Walk;
- Push and/or pull;
- Bend;
- Balance;
- Crouch;
- Stoop;
- Kneel;
- Grip and manipulate objects; and
- Reach overhead and in other directions.
A doctor should also provide information regarding a patient’s range of motion in all major joints.
The form used to provide this type of detailed statement is a residual functional capacity (RFC) form. The insurance company probably uses a generic RFC in all claims, but its form is typically too generic and is used to deny benefits. To obtain an RFC form that may actually assist you in winning your claim, use our free RFC form.
Unfortunately, many doctors are unwilling to provide this type of detailed statement, even though this is exactly what is needed to support their patient’s claim. Despite resistance from medical providers, claimants who are seriously interested in winning their disability claims should strive to obtain this type of statement from their doctor.
Our free Doctor’s Guide to ERISA Disability Claims may help convince your doctor to fill out an RFC form in support of your claim. Download the guide from our website and give it to your doctor when you present the RFC form.
Make Sure Your Documents Are Easy To Read
The best medical records are typed, mentioning all of the patient’s complaints and examination results, noting what treatment was provided, stating the patient’s response to treatment, and detailing future treatment plans and prognosis. Unfortunately, many records don’t contain enough information to determine disability.
Including complete and correct information on all your forms is essential. Any missing or incorrect information can lead to a denial of benefits. Be sure to have your physician note symptoms that are not always measured with lab tests, such as pain. Physicians are known for not documenting a patient’s pain level in their notes, so be sure that they are documenting all your symptoms.
It is important to make all your scheduled appointments and not skip treatments or stop taking your medications while waiting on an LTD decision. If you miss appointments or do not take your medications, it may indicate to the insurer that you do not need treatment as you say you do; this could lead to a denial of benefits.
Legal Representation In Long-Term Disability Claims
Here at the Ortiz Law Firm, we assist long-term disability claimants by compiling and effectively presenting objective evidence to support the LTD claim. If objective evidence is unavailable to prove a claim, we will work to develop a proper administrative record with all available information substantiating the claimant’s disability.
Nick Ortiz is an experienced disability law attorney who has handled disability insurance claims since 2005. He understands how to find and utilize medical and other documentary evidence that will hold up in court.
If your LTD claim has been wrongfully denied or terminated and you’d like to speak to an experienced Pensacola long-term disability insurance attorney about your denied claim, call us at (888) 321-8131 to schedule a free case evaluation. We can help you evaluate your claim and recover the benefits you deserve.
