Beyond Diagnoses: The Role of Symptoms in Disability Claims

How do insurance companies review your claim for disability?  Primarily, they are looking at the symptoms that cause restrictions and limitations, rather than solely focusing on the diagnoses. Why does this matter to the insured?  Because if you have a more unusual disability, or one that is not as easy to categorize, it does not mean that your insurance company can deny your claim because of it. They are supposed to be looking at your documented symptoms, and how much those symptoms create restrictions and limitations on your ability to work.

The Power of Symptoms: When it comes to disability claims, it’s essential to shift our focus from diagnoses to symptoms. Why, you ask? Well, while diagnoses provide a name for a medical condition, it’s the symptoms that truly impact our daily lives. Insurance companies understand this and base their review process on the symptoms that result in restrictions and limitations, affecting our ability to work and carry out daily activities.

Understanding Restrictions and Limitations: Before we dive deeper, let’s clarify what we mean by restrictions and limitations. Restrictions refer to the activities or tasks you’re unable to perform due to your symptoms. For example, if you have severe back pain, you may be restricted from lifting heavy objects or sitting for prolonged periods. Limitations, on the other hand, encompass the impact these restrictions have on your overall ability to function, both professionally and personally.  Insurance companies want to hear from your doctors about what you can and cannot do, and how much time in a day you can do restricted activities.  Can you only stand or walk one hour out of an 8 hour day?  Do you need to take a movement break every 15 minutes, for a half hour?  Are you able to type, but only for a total of an hour a day?  These are your restrictions and limitations.

Reviewing the Evidence: When assessing a disability claim, insurance companies carefully evaluate the evidence provided. This includes medical records, diagnostic tests, and, most importantly, documentation of the symptoms, restrictions, and limitations experienced by the insured. These documents act as a roadmap, painting a clear picture of how the individual’s condition affects their ability to carry out essential tasks. Insurance companies like quantifiable data and “evidence” of your disaibility. When your disability cannot easily be confirmed by medical testing, restrictions and limitations provide another set of data for the insurer to review.

Peer Reviews: Insurance companies often consult with medical professionals during the review process. These professionals play a major role in the insurance company’s understanding the impact of an individual’s symptoms on their ability to work and function. They review medical records and examine test results as the primary evaluation of the disability claim.  These medical professionals are usually employees of the insurer, or contractors with them.  If the insurer gets an “independent” evaluation, it is through a third party company that hires the same doctors over and over. These doctors tend to get much or all of their income through these consultations.  The insurer is supposed to use the correct specialist to review a specific medical issue, but too often relies on a generalist, or a specialist in another area entirely. These in-house doctors may reach out to your treating physicians to ask questions about the restrictions and limitations they have placed on you.

The Importance of Documentation: When it comes to disability claims, thorough and accurate documentation is key. It’s crucial to keep a detailed record of your symptoms, including when they started, their frequency, and their severity. Keep a symptom journal. Additionally, be sure to document any restrictions or limitations they impose on your daily life. This information serves as solid evidence that helps insurance companies understand the true impact of your condition.  Make sure you to inform your treating physicians as well each time you have an appointment. The insurer will consider the visit notes of your doctor to be more reliable than your journal.

Articulating Your Experience: Effectively communicating your experience is paramount when filing a disability claim. While medical records and test results are essential, it’s equally important to describe your symptoms, restrictions, and limitations in a clear and detailed manner. Paint a vivid picture of how your condition affects your day-to-day life, making it easier for insurance companies to comprehend the challenges you face.  This applies to both your communications with your insurer, and with your doctors.

The Whole Picture Matters: Insurance companies are supposed to take a holistic approach when reviewing disability claims. The law requires that a diagnosis alone does not provide a complete understanding of an individual’s limitations. By considering the symptoms and their impact, they can better assess the degree of disability and determine the appropriate benefits for the insured.

Consulting with legal professional: Navigating the disability claim process can be complex. The insurance company has an entire division of lawyers advising them on how to deny claims in a way that will not result in exposure to the insurer.  This is why having your own lawyer specializing in disability claims can be immensely helpful when putting together your claim or your appeal of a denial or termination. Lawyers can guide you in identifying and gathering the necessary documentation, getting any useful testing, articulating your experience, and ensuring your claim receives the attention it deserves.

Conclusion: In the world of disability claims, it’s essential to look beyond diagnoses and focus on the symptoms that cause restrictions and limitations. Insurance companies are required under the law to recognize the power of symptoms and thoroughly review claims based on their impact on an individual’s ability to function. By accurately documenting your experience, effectively communicating your challenges, and seeking assistance when needed, you can navigate the process with confidence. Remember, your symptoms tell the story, and by emphasizing their significance, you can ensure a fair evaluation of your disability claim.

Embrace the power of symptoms and advocate for yourself in the realm of disability claims. Stay informed, stay proactive, and let your own experience of your symptoms as carefully documented by you be the driving force behind your journey towards securing the benefits you deserve.