Disability insurance companies are highly skeptical of disabled workers. Without supporting evidence, you cannot win your disability insurance benefits. Thus, key issues in every ERISA disability case are: What types of evidence do you need, and how much evidence do you need?  Experienced ERISA disability claims lawyer, Jonathan F. Feigenbaum, answers those questions in this post.

FIRST, understand your policy’s definition of disability.  Every disability insurance plan is different. Before you file for benefits, request a copy of your policy’s summary plan description (SPD). The SPD will explain how your policy defines disability. Typically, you will either have to show that you cannot perform your “own” occupation or “all” occupations.

Under an “own occupation” plan, you must show that you cannot perform the material and substantial duties of your job. An inability to perform even one job function should result in a finding of disability. “All occupation” plans have a tougher standard of disability. You must prove that you cannot perform any job (including the simplest and easiest occupations) within the national economy.

You should also review your SPD for exceptions and exclusions. Some disability insurance plans cover illnesses and accidental injuries. Other policies only cover illnesses. There also may be exceptions for certain types of illnesses (like addiction) and pre-existing conditions. Once you understand the requirements of your disability insurance policy, you can tailor your evidence to meet its terms.

THEN, gather supporting evidence.  A successful ERISA claim requires multiple types of evidence:

(1)      Medical Evidence

Medical evidence is vital to a disability insurance claim. Medical records help the claims examiner understand your diagnoses, symptoms, treatment protocols, and functional abilities. It is very hard to win disability benefits without consistent medical documentation of your conditions and limitations. Medical evidence may include:

  • Doctor’s notes explaining your symptoms, diagnoses, and restrictions;
  • Diagnostic testing reports (like MRI’s, x-rays, and EKG’s);
  • Letters from your doctors explaining your conditions and ability to work;
  • Functional capacity testing; and
  • Independent medical examination (IME) reports.

It is important to seek medical treatment, when necessary. Make sure to provide good explanations of your symptoms and history when you see a doctor. Giving your doctors complete and accurate information will help diagnose and treat your conditions, and will serve as evidence in your disability insurance claim.

When you file a disability insurance claim, the claims examiner should order all of your medical records. Make sure to give the examiner a complete list of your treating medical providers. It is also in your best interest to follow up with the claims examiner. Sometimes, the examiner does not get your complete medical record, and then denies benefits due to lack of information.

(2)      Vocational Evidence

Vocational evidence is evidence related to your training, qualifications, and ability to transition to other types of work. It may include job descriptions and reports from vocational experts. The vocational analysis will vary, depending on whether you have an “own” or “all occupation” policy.

Again, if you are covered by an “own occupation” policy, you must show that you cannot perform your current job. The claims examiner (or a vocational expert) will evaluate your job description and functional limitations. Sometimes, a claims examiner will use a general job description or the Department of Labor’s Dictionary of Occupational Titles to assess your ability to do your “own occupation.” It is probably in your best interest to provide the insurance company with your actual job description (as provided by your employer, if available). Sometimes, general job descriptions include lighter and easier activities than your actual job functions, which can result in a denial of benefits.

An “all occupation” policy involves a different analysis. Instead, you must show that you are unable to perform any work within the national economy. A vocational expert may perform a transferable skills analysis and a labor market survey to assess the availability of work within your skills and restrictions.

A transferable skills analysis reviews your educational background, experience, and other skills. Sometimes, a worker’s skills are broader than his or her work experience. For example, a factory worker may volunteer for a non-profit organization and have significant computer or administrative abilities. A transferable skills analysis considers all of these elements and sets out your marketable skills and experience.

In a labor market survey, a vocational expert will search for jobs that are within your restrictions and skills. The expert will list jobs within your abilities and their rates of pay. This evidence will be used to decide whether you are unable to perform any occupation under the policy.

(3)      Your Statements to Insurance Company Representatives

During the claims process, the insurance company will ask you for information. This information may be obtained through:

  • Forms and other documents;
  • Interviews; and
  • Independent medical examinations.

Your statements will become part of the record in your disability claim.

It is important that you give the insurance company honest and accurate information. If you exaggerate your symptoms, the claims examiner will question your credibility. However, if you minimize your problems, claims examiners typically use your statements to deny benefits. When you are completing a form or answering questions, you should:

  • Describe your daily activities as you currently perform them (not at your pre-disability levels);
  • Detail your need for rest periods and breaks;
  • Note negative side effects (including drowsiness) from your medications; and
  • Describe any accommodations or special help you need with activities.

This is also true for independent medical examinations (IME’s). An IME may be performed at the request of the insurance company or a lawyer. The IME doctor is paid by whoever requests the exam. Insurance company IME doctors sometimes slant their reports to deny benefits, so it is important to give accurate information and a full effort during an IME. Exaggerating your symptoms may damage your credibility and lead to a denial of benefits.

Contact an Boston ERISA Disability Claims Lawyer to Help Build a Strong Case for Benefits

ERISA law contains strict evidentiary rules. Once the insurance company’s decision is final, it is nearly impossible to submit additional evidence. If, like many disabled workers, you are not comfortable interpreting disability insurance policies, reading medical evidence, and obtaining additional evidence to “stack” the record in your favor, contact an experienced ERISA disability claims lawyer to help you.  You can reach us by phone or email to schedule a time to talk about your situation.