Autoimmune Diseases

Understanding Autoimmune Diseases and Their Impact on Full-Time Work

Autoimmune diseases are a complex group of conditions characterized by an abnormal immune response, where the body’s immune system mistakenly attacks its own healthy cells and tissues. There are numerous autoimmune diseases, each with its own unique set of symptoms and effects. These conditions can significantly impact an individual’s ability to maintain full-time employment due to the chronic nature of the diseases and their wide-ranging effects on physical, mental, and emotional well-being. 

Autoimmune diseases occur when the immune system, which is designed to protect the body from harmful invaders like bacteria and viruses, becomes overactive and targets healthy cells and tissues. The exact cause of autoimmune diseases is not fully understood, but factors such as genetics, environmental triggers, and hormonal imbalances may contribute to their development.

Examples of Autoimmune Diseases

1. Rheumatoid Arthritis (RA): RA primarily affects the joints, causing inflammation, pain, stiffness, and reduced mobility. The chronic nature of the disease, along with joint deformities and systemic symptoms, can make physical tasks at work challenging and lead to increased fatigue.
2. Systemic Lupus Erythematosus (SLE): SLE, or lupus, is a systemic autoimmune disease that can affect various organs and systems, including the skin, joints, kidneys, heart, and lungs. The unpredictable and fluctuating nature of SLE, along with symptoms such as fatigue, joint pain, skin rashes, and organ involvement, can make it difficult to maintain regular work schedules and perform physically demanding tasks.
3. Multiple Sclerosis (MS): MS is a chronic autoimmune disease that affects the central nervous system. It can lead to symptoms such as fatigue, muscle weakness, numbness, coordination problems, and cognitive difficulties. The unpredictable nature of MS flare-ups and the varying degrees of disability can significantly impact work productivity and performance.
4. Psoriasis and Psoriatic Arthritis: Psoriasis is a skin condition characterized by red, scaly patches on the skin, while psoriatic arthritis involves joint inflammation. Both conditions can cause pain, joint stiffness, skin discomfort, and reduced range of motion. These symptoms can limit physical abilities and make it challenging to perform tasks required for full-time work.
5. Inflammatory Bowel Disease (IBD): Crohn’s disease and ulcerative colitis are examples of inflammatory bowel diseases. These conditions cause chronic inflammation in the digestive tract, leading to symptoms such as abdominal pain, diarrhea, fatigue, and malnutrition. The unpredictable nature of IBD flare-ups and the need for frequent restroom access can make it difficult to maintain regular work schedules.
6. Sjögren’s Syndrome: Sjögren’s syndrome primarily affects the salivary and tear glands, leading to dry mouth and eyes. It can also affect other organs, causing symptoms such as joint pain, fatigue, and difficulty swallowing. Dryness-related symptoms and fatigue can impact work performance, especially in tasks that require clear vision, vocal abilities, or extended periods of focus.

Ways Autoimmune Diseases Can Disable Someone from Full-Time Work

1. Fatigue and Energy Drain: Many autoimmune diseases cause chronic fatigue, even with adequate rest. Fatigue can make it challenging to sustain full-time work and may require frequent breaks or reduced working hours.
2. Chronic Pain and Physical Limitations: Autoimmune diseases often involve chronic pain and physical limitations. Joint pain, muscle weakness, stiffness, and reduced mobility can limit the ability to perform physically demanding tasks required for full-time work.
3. Cognitive Impairment: Some autoimmune diseases, such as SLE and MS, can cause cognitive impairment, including difficulties with memory, concentration, and processing speed. This can hinder productivity, decision-making, and tasks that require cognitive acuity.
4. Fluctuating Symptoms and Unpredictable Flare-ups: Many autoimmune diseases have unpredictable patterns of symptom flare-ups and remission. The fluctuating nature of these conditions can make it challenging to maintain consistent work attendance, adhere to strict schedules, or meet deadlines.
5. Medication Side Effects: Medications used to manage autoimmune diseases may have side effects that impact work performance. These can include drowsiness, gastrointestinal disturbances, or cognitive impairment.
6. Emotional and Mental Health Impact: Living with a chronic autoimmune disease can lead to emotional and mental health challenges such as depression, anxiety, and stress. These conditions can affect overall well-being and impact work productivity and satisfaction.
7. Workforce Accommodations: Depending on the severity of symptoms and limitations, individuals with autoimmune diseases may require workplace accommodations. These can include flexible work hours, modifications to workstations or equipment, or the option to work remotely.

What Insurers- and Courts – Consider When Reviewing Autoimmune Disease Disability Claims

Insurers and courts focus on the symptoms of a disability rather than the diagnosis when determining if a claimant is disabled. At least, they are supposed to look at symptoms. All too often, when faced with a little-understood diagnosis like most autoimmune diseases, insurers take the opportunity to deny the claim due to the diagnosis rather than the symptoms. Courts do not support this approach.

• Dr. Mirick, a biostatistician, had unspecified connective tissue disease. Mirick v. Prudential Ins. Co. of Am., 100 F. Supp. 3d 1094, 1097 (W.D. Wash. 2015). After working through it for over a decade, her condition worsened, and she began to experience significant cognitive issues as well as increased pain and headaches. Her doctors all supported disability. Prudential Insurance denied the claim due to “no acute findings” in the medical records. Dr. Mirick returned to work part-time out of economic necessity. The Court held that the testing in the record was more than sufficient for a finding of disability and that the fact that she was forced to return to work did not demonstrate otherwise. 
• Maurice Mason, a corporate manager at FedEx, developed a rare autoimmune disease that caused his muscles to lock up uncontrollably at random times. The medication to try to manage this created significant cognitive issues. His doctors supported his claim for disability, as did his employer, who agreed he could not perform his current sedentary role due to his physical and cognitive disabilities. Mason v. Fed. Express Corp., 165 F. Supp. 3d 832, 844 (D. Alaska 2016). Despite this, Aetna denied his claim for benefits on the basis that the testing and medical records did not provide enough evidence of specific limitations. The Court held that Aetna failed to accurately inform Mr. Mason of what he needed to do to perfect his claim, it failed to provide the reports on which it relied for Mr. Mason’s use in his appeal, and failed to provide medical records to its internal reviewers. Aetna failed to consider the positive lab results and objective findings throughout the medical record documenting the spasms and pain, and failed to acknowledge the evidence of the cognitive effects of the medication. The Court held that Mr. Mason was entitled to benefits.
• In Bilyeu v. Morgan Stanley Long-Term Disability Plan, No. CV-08-02071-PHX-SRB, 2015 WL 4134447, at *1 (D. Ariz. June 2, 2015), the plaintiff was a Team Leader at Discover Financial Services. She had Behçet’s Syndrome, an autoimmune disease that causes inflammation of the blood vessels and, with it, body sores, rashes, and lesions. Plaintiff also found that her condition was made worse by stress and anxiety. The insurance policy offered by Unum included a Mental Illness Limitation where benefits “for” mental illness were restricted to 24 months. The Court held that where there was no evidence that the physical aspects of Behçet’s Syndrome were disabling, the disability was subject to the 24-month Mental Illness limitation.

Legal Assistance is Key in Successful Insurance Claims Results

With autoimmune diseases, insurers may be more likely to question the diagnosis itself. But even if the diagnosis isn’t clear or well known, if you can demonstrate disabling symptoms, the diagnosis itself should not be a reason to deny the claim. Just like any other claim, an insured with an autoimmune disease must be able to demonstrate evidence of why the disease’s symptoms restrict and limit abilities to the point where the insured can’t work. Any available testing is important to obtain, as are all objective, observable evidence of your doctors and peers. Keep a symptom journal. Let the insurer know what is happening on a given day and how it affects your physical and cognitive abilities.