Medical Conditions That Qualify for Long-term Disability

Long-term disability (LTD) is a disability insurance policy that provides coverage to an employee who is unable to work for a long period following an illness, injury, or accident. Just as for other injuries, medical record retrieval and review are very important considerations when claiming for LTD also. LTD coverage is available for a portion of the employee’s income while he/she is absent from work. An illness or injury could be aggravated by other illnesses and injuries. Also, the disabled person may be suffering from pain and fatigue as well as the negative side effects of medications. All these issues are considered when determining long-term disability coverage. A combination of impairments or medical conditions, when found to be severe enough to prevent the claimant from working, may qualify for LTD coverage.

Medical Conditions That May Be Eligible for LTD Coverage

Some medical conditions may be so disabling that they may automatically qualify for approval under the claimant’s insurance policy. These include total deafness, total blindness, and amputation.

Here is a list of other conditions that may qualify for LTD benefits on the basis of a comprehensive medical records review.

• Musculoskeletal disorders
• Neurological disorders
• Autoimmune disorders
• Special senses and speech disorders
• Mental disorders
• Respiratory disorders
• Cardiovascular and circulatory disorders
• Infections and parasitic diseases
• Digestive disorder
• Hematological disorders
• Genitourinary impairments
• Endocrine, nutritional, and metabolic diseases, and immunity disorders
• Skin disorders
• Cancer and malignant neoplastic diseases
• Impairments of multiple body systems
• Symptoms, signs and subjective conditions-related impairments

Chronic fatigue syndrome, degenerative disc disease, fibromyalgia, Lupus, HIV/AIDS, cancer, Crohn’s disease, bipolar disorder, back and neck problems, epilepsy, Parkinson’s disease, non-epileptic seizures, and multiple sclerosis (MS) are among the medical conditions that may qualify for LTD insurance. These fall under one or other of the abovementioned impairment groups.

Medical Records Review Key to Determining Disability

When determining disability, insurers rely on the claimant’s medical records. They review whether the medical chart properly conveys the claimant’s health condition, pain, fatigue, inability to work and so on. All symptoms and disabilities must be properly documented in the medical records if the disability claim is to be approved for LTD benefits by the insurance company.

Attorneys representing claimants say that the claimant’s disabling injuries/illnesses must ideally be presented in combination if benefits are to be granted. A legal case chronology prepared by expert medical record reviewers is a valuable tool for attorneys, giving them a clear outline of the claimant’s health condition, injury, illness, treatments provided, pain and fatigue and other important details. Attorneys strive to understand how the claimant’s illnesses and injuries affect his or her ability to perform routine activities, and how these negatively impact his/her ability to perform full-time work activities. For this, they may seek the services of a medical peer review company. The medical record review report provided by professional reviewers enable them to establish solid connections between the claimant’s recorded medical conditions and the resulting disabilities. This is most essential to develop the disability case properly and present it convincingly in a court, if required.

What Medical Evidence Is Needed to Establish Disability?

Claimants and their attorneys need to present objective medical evidence that will convince the insurance company that a disability or impairment exists. Such evidence includes medical symptoms and lab test findings. Symptoms include any physiological, psychological, or anatomical abnormalities that a medical provider observes and records in the patient’s medical chart. These signs and symptoms are shown by medically acceptable diagnostic techniques. Psychiatric signs include abnormalities of behavior, thought, memory, mood, development or perception. Lab findings include physiological, psychological or anatomical phenomena that are revealed via use of laboratory diagnostic techniques such as ECG, X-rays, MRIs, blood tests, CT scans, and psychological tests. These objective tests are more significant when the disabilities are hidden (e.g. chronic pain syndrome, chronic fatigue syndrome, chronic back pain, fibromyalgia and so on) and are usually diagnosed based on the claimant’s complaints. Objective medical evidence regarding whether a claimant is physically capable of performing his/her regular work may be obtained through a functional capacity evaluation (FCE) test.

Each insurance plan may be unique, and so the claimant must review his or her plan details to understand eligibility for LTD benefits. Some plans may have a maximum pay-out for chronic medical conditions such as back pain, arthritis, and carpal tunnel syndrome. There may be some common limitations and exclusions such as mental health conditions, pre-existing conditions, alcohol and substance abuse, and so on.

As a medical peer review company assisting disability attorneys, MOS (Managed Outsource Solutions) understands that insurance policy language varies considerably from one health plan to another. Therefore, to understand the various limitations and exclusions, and to ensure that they file a successful claim, claimants should ideally be represented by a long-term disability attorney.