How Disability Insurers Assess Functional Capacity in Long-Term Disability Claims

When you file a long-term disability (LTD) claim, you are telling the insurance company that you can no longer perform the duties of your job due to a medical condition. But how does the insurer decide whether you are truly unable to work? They evaluate your “functional capacity”, what you can and cannot do in a work setting. Understanding this process is key to building a strong claim.

It can be incredibly frustrating when an insurer reduces your complex medical condition to a simple checklist. You know you cannot work, but they seem focused only on what you can do. This is a common and difficult part of the claims process, but you are not powerless.

Proving Physical Limitations

For physical disabilities, insurers look for objective evidence of your limitations. It’s not enough to say you have back pain; you must show how that pain prevents you from functioning in your job. The insurance company will assess your capacity for activities that are fundamental to most jobs.

They want to know:

• How long can you sit, stand, or walk? An insurer will want specific time limits, such as being able to sit for only 20 minutes at a time.
• How much can you lift, carry, push, or pull? This is often measured in pounds (e.g., cannot lift more than 10 pounds).
• Can you bend, stoop, or reach? Your ability to perform these motions throughout a workday is critical.

Your doctor’s notes are essential here. They must clearly document these specific limitations rather than just stating your diagnosis. A Functional Capacity Evaluation (FCE), performed by a physical or occupational therapist, can provide powerful, objective evidence that insurers find difficult to dispute.

Demonstrating Cognitive and Mental Limitations

Proving cognitive or mental health limitations can be more challenging because they are not as easily measured as physical ones. Insurers are often skeptical of claims based on conditions like “brain fog,” anxiety, or depression.

To approve a claim based on cognitive limits, they look for documented evidence of your inability to:

• Concentrate and maintain focus: Can you pay attention for extended periods?
• Understand, remember, and apply information: Are you able to follow complex instructions or recall important details?
• Interact appropriately with others: Can you manage workplace stress and collaborate with colleagues?
• Adapt to changes and make decisions: Is your judgment impaired?

Specialist documentation is crucial. Reports from a neuropsychologist who has conducted formal testing can provide the objective proof needed to validate your cognitive struggles. Detailed notes from your psychiatrist or therapist that describe how your symptoms impact your ability to perform job-related tasks are also vital. Your own detailed journal of daily struggles can help paint a complete picture for the insurer.

Contact Us for Help

A disability claim is not just about your diagnosis; it is about how that diagnosis limits your ability to function. Providing clear, specific, and well-documented evidence of your functional capacity is the most important step toward getting your claim approved. If your claim has been denied, it is often because the insurer believes your functional limitations are not severe enough. Monahan Tucker Law can help you gather the right evidence to prove them wrong. Get in touch with us today.