Musculoskeletal Disorders & Long-Term Disability
It’s pain you never thought you would have, but it’s there, preventing you from living life to the fullest. Now you’re faced with filing a long-term disability claim, and aren’t sure what to expect.
Maybe you were injured at work, had a car accident, or the condition developed over time. Whatever the cause, a musculoskeletal condition can leave you pained with limited abilities. A condition that worsens may leave you in even more pain, disabled, and unable to work.
Musculoskeletal conditions that may result in long term disability include:
- Carpal tunnel syndrome
- Degenerative disc disease
- Ehlers-Danlos Syndrome (genetic disorder that affects the connective tissues)
- Herniated (ruptured) discs
- Neck and back pain
- Muscular dystrophy
- Rheumatism/Rheumatoid arthritis
- Spinal stenosis
Any one of these painful conditions can leave you disabled and unable to work. Musculoskeletal disorders are the most frequent types of disability claims, as well as the most commonly denied. Because these disorders aren’t easily visible and documented, quantifying the pain and restriction that goes with them is problematic.
Additionally, these disorders are usually not work-related, which means you’ll be required to use sick days, vacation days, and then apply for short-term disability (if you have it) to cover your monthly expenses. Long-term disability (LTD) is the next step after these resources are exhausted, and are used if you’ve been out of work for 90 days, or expect to be.
Why Your Long Term Disability Claim Was Denied
Because each injury or illness has a range of symptoms, including pain, lethargy, mental and physical exhaustion, we believe it’s important to present a holistic picture of how your condition affects you on a daily basis. Fatigue, cognitive issues, and medications with side-effects are just some of the factors that can affect your overall quality of life with a disabling condition.
Unfortunately, insurers tend to judge a claim based solely on the condition alone without considering how that condition impacts your life on a day-to-day basis.
Why would an insurance company deny your claim when you’re most in need of help? It’s a common stalling tactic to deny paying your claim, along with continuous requests for “additional information.” They may also give you other reasons for claim denial, including:
- No testing and/or medical support from your doctors
- No fundamental connections between your condition and the ability to work in either your own occupation or any other
- You have no impartial basis for a diagnosis or restrictions from your condition
- The company has video surveillance of you doing what your physician claims you are unable to
But an initial denial is not the end of your claim. That’s when it’s time to call an ERISA-trained attorney at who understands the law and knows what to do next.
Process for ERISA Long-Term Disability Claims
Employer-sponsored LTD plans are governed by the Employee Retirement Income Security Act of 1974, commonly called ERISA. Overseen by the US Department of Labor, ERISA “sets the minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in the plans.”
ERISA allows you to file an administrative appeal of a denial of long term disability benefits, and if the denial is upheld, you can then sue your insurer in federal court. In addition, employers are required to provide basic information on their plans under ERISA, including:
- Information on what is and isn’t covered under the plan
- Instructions for filing a claim after an employee becomes disabled
- Additional information regarding the company’s appeal process should the insurer deny the employee’s claim
While ERISA sounds like it favors the employee, it actually favors the insurer. Laws covering long-term disability are very complicated, your best chance at winning on appeal is with the help of a long-term disability attorney who understands both LTD and ERISA.
When submitting your appeal, you need to provide a wide range of documentation, including:
- Medical records
- Doctors notes and statements
- Diagnostic results (X-Rays, blood tests, etc.)
- Any other documentation that can prove your claim
An long term disability attorney can advise you on the documentation to submit, how much, what to request, deadlines, and all applicable ERISA requirements.
If your claim is denied on appeal, you may decide to take your case to trial. Unlike most kinds of legal cases, you will not be allowed to add any additional evidence into your file. The judge will only see what is already available. This is why it’s vitally important to add as much information into your claim file at the outset, and acquire as much of it as you can.
ERISA's “Discretionary Clause”
You may have been informed about this clause when discussing your LTD policy with your employer or agent. It is simply language that’s written into the policy that gives the insurer leeway to limit or deny claims based on their own discretion, as well as prohibits overturning the decision by a court of law. It has been used many times to deny claims to policyholders.
California, Texas, Hawaii, and Washington are among the 18 states that have outlawed the use of a discretionary clause. Missouri has not ruled on the matter, so discretionary clauses are legal here.
Our Long Term Disability Lawyer Can Help
The last thing you need when you’re suffering with a musculoskeletal condition is an insurance company denying your claim or implying that your condition isn’t serious enough. Even worse, having your insurer terminate your benefits without much explanation. If you’re in this position, you need to act fast or lose your right to appeal completely.
Don’t let an insurance company have the upper hand. Whether you need help filing your application or starting an appeals process, our attorneys are ready to help. Contact Kevin today at 816-203-0143 to schedule an appointment. We’ll review your denial letter for free, and offer you a strategy for taking the next steps.