Under many long-term disability policies, “Disabled” means “limited from performing the material and substantial duties of one’s regular occupation due to sickness or injury,” with a corresponding “twenty percent or more loss in indexed monthly earnings.”
Objective Evidence of Disability
The disability benefit attorneys of MyLTDbenefits.com use clinical examinations standardly accepted in the practice of medicine to diagnose or evaluate a condition, which may include fever, chills, confusion, dizziness, shortness of breath, tenderness, abnormal reflexes, motor weakness, altered mental status, confusion, etc. Even symptoms such as fatigue may be verified on clinical examination, when an individual appears tired or moves slowly. Similarly, pain may be verified on clinical examination, when testing elicits discomfort. The key to proving that you have offered “objective evidence” in the form of clinical examinations is to link the verified symptoms with your diagnosis. A good example of this is found in the case of individuals suffering from Fibromyalgia.
Similarly, in another case the court held:
People with fibromyalgia have generalized pain, achiness, and stiffness all over their bodies. The diffuse pain may be referred from various tender points in the body. The tender points are very painful, but people with fibromyalgia may not even realize these particular areas hurt until pressure is applied to them. The other main characteristic of fibromyalgia is chronic fatigue, probably related to disturbed sleep patterns. Sufferers often complain of waking up as tired as they were when they went to sleep having continued fatigue throughout the day.
In another recent case, the court held that trigger-point findings consistent with fibromyalgia constitute objective evidence of the disease.
Other decisions in Minnesota, Iowa, Missouri, Arkansas, Nebraska, South Dakota and North Dakota have held that the insurer’s failure to obtain an independent medical examination (IME) can constitute evidence of bias or a procedural irregularity. Additional evidence that may be considered “objective,” includes documentation of physical limitations such as office records, forms requested by the insurer and prognosis or residual functional capacity information.
Often, an insured capable of performing some of the material duties of his occupation will nevertheless claim total disability benefits, without regard to a partial/residual disability clause in the policy. Courts deciding long-term disability benefits cases in Minnesota, Iowa, Missouri, Arkansas, Nebraska, South Dakota and North Dakota have taken a functional approach to resolving the conflict, weighing the importance of the duty the claimant is unable to perform in determining total disability benefits.
Total disability typically exists if the infirmity renders the claimant unable to perform the substantial and material duties of his or her occupation in the usual and customary manner. In one case, Unum determined that Dr. Dowdle, an orthopedic surgeon, was no longer totally disabled when, following an accident, he returned to part-time work, consulting with patients in an office setting. Unum attempted to involve the residual disability clause of the policy. Dr. Dowdle’s pre-disability duties were seeing patients, performing surgery, reading x-rays, interpreting data, and promoting referrals. The Court held that since Dr. Dowdle’s disability prevents him from performing the most important part of his occupation (orthopedic surgeries), he was entitled to total disability benefits.
In another recent case, the claimant suffered from ASHD and returned to work following bypass surgery but ultimately was instructed to leave work because the stressful job was deleterious to his health. The court agreed this was reasonable and the claimant qualified for disability benefits.
The lawyers of MyLTDbenefits.com work from the inception of the long-term disability benefit claim to discern the most important duties of our disabled client.
Long-term disability policy administrators in Minnesota, Iowa, Missouri, Arkansas, Nebraska, South Dakota and North Dakota who fail to conduct a vocational evaluation may be found to result in an unreasonable decision. One such decision required expert vocational evidence in addition to medical evidence when the benefit plan’s definition of disabled hinged on the claimants ability to be gainfully employed.
In addition to the Dictionary of Occupational Titles, the Department of Labor has developed the Occupational Information Network or “O*NET,” a relatively recently updated online database. Although O*NET has been widely available since the late 1990’s, courts have continued to accept use of the DOT. If long-term disability policy defines “own occupation,” however, the DOT and O*NET occupational descriptions maybe irrelevant.
In determining whether the claimant’s disability is mental in nature, the symptom-based approach used by the courts in Minnesota, Iowa, Missouri, Arkansas, Nebraska, South Dakota and North Dakota focus upon whether the manifestations of the infirmity (symptoms) would indicate the existence of a mental illness to a layperson. In that jurisdiction it was found improper for the insurer to consider the cause of a mood disorder because a layperson classifies an illness by its symptoms, not its cause.
The Circuits have reached differing conclusions regarding the ambiguity of a mental illness limitation that fails to specify whether an illness is classified as mental based on its origin or symptoms.
If the policy language fails to specify whether a disability is classified as mental based on its origin or symptoms, the term is ambiguous, and the court will apply the “plain meaning” of the provision to resolve the ambiguity. The disability benefit attorneys of MyLTDbenefits.com have successfully argued that the 2-year mental disability limitation did not apply to mental conditions having an underlying organic cause.
Please contact us to get your long-term disability benefits in Minnesota, Iowa, Missouri, Arkansas, Nebraska, South Dakota and North Dakota . Call 262-785-9606 for consultation. We pride ourselves on providing cost-effective solutions.