You are exhausted. You are in pain. You can hardly concentrate. Your memory is shot and you are feeling depressed and anxious. You may still not (and may never) know what is causing you to feel the way that you do. The one thing you do know is that there is no way that you will be able to do what is required of you at work.
“Invisible Conditions” Are Difficult to Prove
Your family, your colleagues, your doctors–they try to be supportive, but you wonder whether they believe you. You do not want to be perceived as malingering or exaggerating. You want to be believed and supported. Unfortunately, while you may be very good at explaining to your doctors and others how you feel and how your symptoms prevent you from functioning in your daily life, including working, some people will still not be convinced that you are ill or as severely ill, as you describe yourself to be.
This skepticism may be extremely hurtful or at the very least aggravating, if it comes from those you love and from those who you thought you could count on to believe and support you. However, when the skepticism comes from your insurance company in the form of a denial or termination of your LTD benefits, it can be downright devastating.
Your Insurance Company Denied Your LTD Claim for an “Invisible Condition”
Financially, you were relying on your insurance company to provide you with a percentage of your income and to protect your other insurance (like life insurance) while you remain disabled. Without this income from LTD benefits, it will be impossible for you to meet your personal and family’s financial obligations and the risk to your other life and health insurance benefits could have serious consequences, down the road. The stress of having no income and not being able to work can also have serious and long-lasting effects on your mental health and serve to aggravate your existing physical symptoms.
You provided your LTD claims forms to your insurance company (or insurance benefits administrator). You were sure that they would approve your claim. You went to great lengths to describe your symptoms and treatment and explain why you are not able to work. Your doctor, she detailed your symptoms, described your treatment and set out a long list of functional restrictions and limitations. She even attached consultation reports from all the specialists you have seen and indicated upcoming referrals to other specialists and treatment providers. She stated, right on the form, that you are disabled from work and that your prognosis for return to work is unknown. Surely, this will be sufficient medical evidence to support your LTD claim.
Not so. You receive a detailed 3-page letter from your insurance company. The bottom line is that your LTD claim has been denied. What are you to do? Was there anything you could have done differently to have ensured that your LTD claim was approved? Is there a way to now appeal or litigate the denial/termination by proving to your insurance company that your illness is truly preventing you from returning to work?
No “Objective” Evidence of Disability for “Invisible Conditions”
The fact is that insurance companies like “objective” evidence of disability. Objective evidence of disability makes it far simpler for them to determine the nature and severity of a disabling condition and assess whether someone is not functionally able to work and therefore eligible for LTD benefits.
For example, it is easy for someone to rely on x-rays and MRI’s to prove that walking, sitting, and standing are not possible due to visible evidence of damage to the person’s back. If these functional abilities are necessary to complete the “essential duties” of that person’s “own occupation”, then the person’s LTD claim will likely be approved without much more investigation.
Unfortunately, many types of serious disabilities do not lend themselves to being identified by “objective” measures, such as x-rays, CT-scans, blood tests, and other types of measurable diagnostic testing. For example, chronic pain and chronic fatigue conditions are very common disabilities that do not lend themselves to diagnosis by way of the usual objective tools or measures. You may claim to not be able to work due to pain or fatigue, but how does your insurance company know that these “self-reported” restrictions and limitations truly exist or are truly as severe as you claim?
Why Do Insurance Companies Deny LTD Claims for “Invisible Conditions”?
Insurance companies and plan administrators are in a tricky spot when it comes to “invisible conditions” or conditions for which “objective findings” are not possible to provide. On one hand, insurance companies are in the business paying legitimate claims to people who are not medically able to work. Most insurance companies advertise that their mandate is to support dedicated, hardworking people who have either been paying their own premiums or whose employers have been paying premiums for the purpose of protecting their incomes and other benefits, in the event that they are not able to work due to any type of illness or injury.
On the other hand, insurance companies must also be mindful of their financial obligations to everyone they insure; particularly, with respect to maintaining or reserving sufficient assets or funds to ensure that benefits are available to pay all legitimate LTD claims and other financial obligations to any and all insured members or policyholders. Insurance companies have a duty to carefully assess all LTD claims to ensure that only those people who satisfy the “definition of disability” in their plan or policy are paid benefits and only for so long as they continue to meet the terms and conditions of the plan/policy.
Short-Term Disability – The First Step Toward Claiming LTD for an “Invisible Condition”
If you are experiencing disabling symptoms, such as pain, fatigue, depression, or anxiety, and these symptoms are impacting your ability to function in your normal daily activities, including in your work, then you will need to consider your options.
Assuming that your condition is so severe that no accommodations will allow you to do the “essential duties of your own occupation”, then you will need to apply for Sick Leave through your employer. This may be done through an application for Short-Term Disability (STD) benefits to an insurance company or a plan administrator. If your employer does not have STD benefits, you may be paid your salary by your employer and/or you may need to apply for Employment Insurance Sickness Benefits (15 weeks).
The medical information you provided to your employer or in your STD claim might have been sufficient for your employer grant you Sick Leave or to be approved for STD benefits or EI Sickness benefits, however, you the same information might not be sufficient to be approved for LTD.
Remember that your employer is not entitled to know your diagnosis; only the nature of your condition and your functional restrictions and limitations and your prognosis.
