Cognitive impairment, which affects memory, reasoning, concentration, and decision-making abilities, can be life-altering. When cognitive impairment prevents someone from working, they may be entitled to disability benefits through their disability insurance policy. However, these claims are often complex and involve detailed evaluations by disability insurance companies to determine if a claimant qualifies for benefits.
This article will explain how cognitive impairment disability claims are evaluated, what disability insurance companies look for, the role of medical evidence, and the challenges claimants face when seeking approval for their claims.
Cognitive impairment refers to a decline in mental abilities such as memory, attention, problem-solving, and language skills. It can range from mild cognitive dysfunction, sometimes referred to as “brain fog,” to severe conditions like dementia or Alzheimer’s disease. Cognitive impairment can stem from various causes, including:
Cognitive impairments can profoundly impact a person’s ability to perform tasks essential to their job. This often leads to disability claims when the individual can no longer work due to their condition.
Disability insurance is designed to replace a portion of an individual’s income if they become unable to work due to illness or injury. There are two main types of disability insurance:
For individuals with cognitive impairments, long-term disability insurance is often the primary source of financial support once their condition prevents them from performing their job duties. However, obtaining approval for a cognitive impairment disability claim can be challenging due to the subjective nature of cognitive symptoms and the rigorous standards applied by insurance companies.
Disability insurance companies assess cognitive impairment claims using a combination of medical records, cognitive assessments, job duties analysis, and other documentation. The process is often lengthy and detailed, as insurers want to ensure the claim is valid and that the claimant’s condition truly prevents them from working.
Here’s a breakdown of the typical steps involved in evaluating cognitive impairment disability claims:
1. Review of Policy Terms
The insurance company pays benefits that are contractually owed. It therefore will start with the contract language when determining whether or not it owes benefits under that contract. Many contracts require an insured to demonstrate disability from their “own” or “regular” occupation for the first two years of disability. After that they often need to demonstrate disability from “any occupation.” The first question the insurer will ask is whether or not the cognitive impairment needs to be demonstrated based on the insured’s own occupation, or any occupation.
Next, the insurer will look at whether or not there are exclusions in the policy that would result in no coverage. This would generally be a pre-existing condition. Many policies exclude coverage for any condition for which the insured received treatment in the three months prior to starting their current job, if they started that job within one year of filing the disability claim. If the insured saw any doctor or therapist for cognitive concerns, or a medical issue that may be causing cognitive issues, the cognitive disability may be excluded.
Then, the insurer will look to see what the underlying cause of the cognitive disability might be. Many policies have 24-month limitations on benefits for disabilities “caused by or contributed to by” mental health issues. If the cognitive issues stem from depression or other mental health issues, the insurer will assert that they are subject to the 24-month mental health limitation. Some policies also include a 24-month “self-reported” or “subjective” symptom limitation, which applies to any disability that cannot be objectively verified with testing, such as migraines The insurer may also attempt to shoehorn the cognitive disability into this category.
2. Review of Medical Evidence
The next step in evaluating a cognitive impairment disability claim is reviewing the claimant’s medical evidence. Insurance companies rely heavily on medical documentation to determine the severity of the cognitive impairment and whether it meets the policy’s definition of disability.
The medical evidence that insurers typically require includes:
3. Neuropsychological Evaluations
Neuropsychological evaluations are critical in assessing the severity of cognitive impairment. These evaluations are conducted by licensed neuropsychologists who perform a battery of tests to assess various aspects of cognition, including memory, attention, language, and executive function.
Disability insurers often require claimants to undergo independent neuropsychological evaluations to verify their condition. The results of these tests are compared to normative data to determine how much the claimant’s cognitive function deviates from the expected range for their age and education level.
Neuropsychological evaluations help insurers determine whether the claimant’s cognitive deficits are severe enough to interfere with their ability to perform job-related tasks. For example, if a claimant’s job requires high levels of concentration and problem-solving skills, even mild cognitive impairment could prevent them from performing their duties.
4. Functional Capacity Evaluations (FCEs)
In addition to neuropsychological evaluations, disability insurance companies may request a Functional Capacity Evaluation (FCE). FCEs assess the claimant’s physical and cognitive abilities in relation to their job duties.
An FCE typically includes a series of tasks designed to measure the claimant’s ability to focus, follow instructions, solve problems, and recall information. The results of the FCE are used to determine whether the claimant can perform the essential functions of their job despite their cognitive impairment.
For example, a claimant who worked as a software engineer may be asked to complete tasks that test their ability to write code or solve complex algorithms. If they struggle to complete these tasks due to cognitive deficits, it could support their claim that they are unable to return to work.
5. Analysis of Job Duties and Occupational Requirements
To determine whether a cognitive impairment qualifies as a disabling condition, insurers must evaluate how the impairment affects the claimant’s ability to perform their job. This is known as the “own occupation” or “any occupation” standard, depending on the terms of the disability insurance policy.
To evaluate cognitive impairment claims, insurers analyze the claimant’s job duties to determine which cognitive skills are required to perform their work. This analysis may include:
6. Subjective vs. Objective Evidence
One of the major challenges in cognitive impairment disability claims is the distinction between subjective and objective evidence. Many cognitive symptoms, such as memory lapses, difficulty concentrating, or mental fatigue, are inherently subjective and difficult to measure objectively. Insurance companies often place more weight on objective evidence, such as test results, and may be skeptical of subjective reports of cognitive difficulties.
The good news is that courts have consistently held that cognitive testing provides objective evidence of disability. Obtaining supportive cognitive testing is an important step in a successful cognitive disability claim.
7. Surveillance, Perr Reviews, and Independent Medical Examinations
Insurance companies often use surveillance, peer reviews, or independent medical examinations (IMEs) to verify the validity of cognitive impairment claims. Surveillance may involve observing the claimant in public to determine if their behavior is consistent with their reported cognitive limitations. For example, if a claimant is observed driving a car or shopping independently, the insurer may argue that they do not have significant cognitive impairment.
Peer reviews occur when the insurance company has its own doctors review the insured’s medical records and opine on disability. These doctors sometimes are employed by the insurer, and sometimes are provided by a third party service. They do not examine the insured, and often do not consult with the insured’s doctor.
IMEs are conducted by doctors or neuropsychologists hired by the insurance company. These doctors may perform their own evaluations of the claimant’s cognitive function and offer an opinion on whether the impairment is severe enough to prevent the claimant from working. It’s important to note that both peer reviews and IMEs are often biased in favor of the insurance company, and claimants may need to challenge the results if they believe the examination was unfair. Insureds can obtain their own independent reviews or exams to dispute the conclusions of the insurance company doctors.
Claimants who are seeking disability benefits for cognitive impairment can take several steps to strengthen their case:
Cognitive impairment disability claims require careful evaluation by disability insurance companies. Insurers rely on a combination of medical evidence, neuropsychological evaluations, and job analysis to determine whether a claimant’s cognitive impairment qualifies as a disabling condition. While these claims can be difficult to win, claimants who provide comprehensive documentation, undergo proper testing, and seek legal guidance can improve their chances of success. Understanding the evaluation process and preparing a strong case is essential for those seeking disability benefits for cognitive impairment.
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