×
Menu
Search

How Disability Insurance Companies Evaluate Cognitive Impairment Claims

Home//Blog//How Disability Insurance Companies Evaluate Cognitive Impairment Claims

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.

What Is Cognitive Impairment?

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:

  • Traumatic brain injuries (TBI)
  • Stroke
  • Neurodegenerative diseases such as Alzheimer’s or Parkinson’s disease
  • Mental health conditions, including depression or anxiety that impair cognitive function
  • Chronic conditions such as multiple sclerosis (MS)
  • Autoimmune diseases such as ME/CFS, lupus, Epstein Barr, long Covid
  • Substance abuse or medication side effects
  • Side effects of treatment for cancer
  • Aging-related cognitive decline

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.

The Role of Disability Insurance

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:

  1. Short-term disability (STD): Provides benefits for a limited period, usually a few months, after a disability occurs.
  2. Long-term disability (LTD): Provides benefits for an extended period, often until retirement age, if the individual is permanently disabled.

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.

How Disability Insurance Companies Evaluate Cognitive Impairment Claims

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:

  • Physician Reports: Statements from neurologists, psychiatrists, or other treating physicians detailing the claimant’s diagnosis, symptoms, and prognosis.
  • Cognitive Assessments: Objective tests such as the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), or neuropsychological evaluations. These tests help quantify cognitive impairment and measure memory, attention, and problem-solving abilities.
  • Imaging Studies: Brain MRIs, CT scans, or other imaging tests may be required to show structural or functional abnormalities in the brain that support the diagnosis of cognitive impairment.
  • Treatment History: Documentation of any medications, therapies, or treatments the claimant has undergone to manage their condition.

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.

  • Own Occupation: Under an “own occupation” policy, the claimant must demonstrate that they are unable to perform the specific duties of their current job due to cognitive impairment.
  • Any Occupation: Under an “any occupation” policy, the claimant must prove that their cognitive impairment prevents them from performing any job for which they are reasonably qualified by education, experience, or training.

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:

  • Job Descriptions: The claimant’s official job description, which outlines their daily tasks and responsibilities.
  • Employer Statements: Input from the claimant’s employer regarding the cognitive demands of the job and any accommodations that were attempted before the claimant stopped working.
  • Vocational Expert Assessments: In some cases, insurers may consult vocational experts to evaluate whether the claimant’s cognitive impairment prevents them from performing their job or any other suitable occupation.

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.

Tips for Strengthening Cognitive Impairment Disability Claims

Claimants who are seeking disability benefits for cognitive impairment can take several steps to strengthen their case:

  1. Comprehensive Medical Documentation: Ensure that all medical records, test results, and physician statements clearly document the extent of cognitive impairment and how it impacts the ability to work.
  2. Neuropsychological Testing: Undergo thorough neuropsychological testing to provide objective evidence of cognitive deficits. These evaluations are often crucial in proving the severity of impairment.
  3. Detailed Job Descriptions: Work with a vocational expert or attorney to provide a detailed analysis of job duties and how cognitive impairment affects the ability to perform those tasks.
  4. Witness Statements: Collect statements from coworkers, supervisors, family members, or friends who can attest to the claimant’s cognitive decline and how it has impacted their work performance.
  5. Consult an Attorney: Cognitive impairment disability claims can be complex, and claimants may benefit from consulting an attorney who specializes in disability insurance claims. An attorney can help navigate the claims process, gather necessary evidence, and challenge unfair denials.

Conclusion

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.

 

Share Post on:

Categories

Archives

Are You Faced with
a Difficult Situation?

We Will Champion Your Case.

img

Schedule A Consultation

Helping clients in California, Oregon, Washington, Nevada, and Arizona.