If an injury, illness, or other serious medical impairment keeps you from working on a full-time basis, you may be entitled to get long-term disability benefits. Unfortunately, insurance companies can make it challenging for even qualified people to secure long-term disability. It is crucial that claimants know what insurers are actually looking for during disability review. At The Law Office of Paul J. Dombeck, PLLC, our Phoenix long-term disability attorney puts clients first.
The Policy Definition of Disability Matters
What qualifies as a disability? The answer is “it depends.” For long-term disability claims in Arizona, the specific definition of your policy matters. Indeed, one of the first things an insurance company looks for in a long-term disability review is whether the claimant satisfies the policy’s definition of “disability.” It is that definition that controls much of the case.
Some policies use an “own occupation” standard, meaning the claimant must prove that he or she cannot perform the material and substantial duties of his or her regular occupation. Other policies later shift to an “any occupation” standard, meaning the claimant must prove an inability to perform other work for which he or she is reasonably fitted by education, training, or experience.
The distinction is critical because a claimant may be disabled from a physically demanding job but still face denial if the insurer concludes that he or she can perform sedentary work. Long-term disability benefits that may have been approved under a particular definition of the term “disability” may actually be denied under a different policy’s definition.
Your Medical Records are Key to Building a Strong Claim: Objective Medical Evidence
Insurers carefully review the medical record. Along with other things, they typically look for diagnosis, test results, clinical findings, medication history, treatment compliance, referrals, surgical records, imaging, lab work, specialist notes, and longitudinal documentation of symptoms. A diagnosis alone is rarely enough. The insurer wants to know how the condition functionally limits the claimant’s ability to work on a full-time, reliable basis. Unfortunately, this is where many valid claims run into trouble. Gaps in treatment, missed appointments, or vague chart notes may be used by the insurer to argue that the impairment is not severe enough to prevent work.
Tip: Medical records are the foundation of your claim. You need to seek the proper medical care for your condition and ensure that you attend all required follow-up appointments. An experienced Arizona long-term disability attorney can help you put together your medical records so that you are in the strongest possible position for your claim.
Functional Capacity, Reliability, and Full-Time Work Ability are All Relevant
Long-term disability reviews are not supposed to focus only on whether a claimant can do isolated tasks. The key question is whether the claimant can perform sustained work activity with reasonable consistency. Insurers look at functional capacity. Among other things, this includes a claimant’s ability to:
- Sit;
- Stand;
- Walk;
- Lift;
- Carry;
- Type;
- Focus;
- Interact with others;
- Maintain pace; and
- Complete job tasks.
Notably, reliability is often the decisive issue. A person may be able to perform some work tasks for short periods but still be unable to maintain competitive employment because of flare-ups, absences, medication side effects, cognitive lapses, pain escalation, or the need to lie down during the day. Insurers may minimize these limitations unless they are clearly documented.
Less Common, But Can Happen: Surveillance, Social Media, and Daily Activities
In most cases, long-term disability claims are reviewed based on the actual application documents provided. With that being said, a more comprehensive review can absolutely happen. Insurance companies frequently compare reported limitations against daily activities. Among other things, they may review claim forms, medical records, social media posts, public information, and sometimes surveillance footage. If the claimant reports severe restrictions but is observed driving, shopping, walking a dog, attending an event, traveling, or doing household tasks, the insurer may argue that the claimant is more functional than alleged.
Understanding the Importance of the Administrative Record
If the policy is employer-sponsored, the claim may be governed by ERISA. That makes the administrative record extremely important. In many ERISA cases, the evidence submitted during the claim and appeal process becomes the core record reviewed later in litigation. If medical opinions, vocational evidence, job duty proof, witness statements, or testing are missing from the record, it may be difficult to add them later.
Insurance companies know this. During review, they look for gaps: incomplete physician forms, unsupported restrictions, inconsistent records, lack of specialist care, missing job descriptions, weak vocational evidence, and failure to address the policy’s specific disability standard. They may also rely on paper reviews by consulting physicians who never personally examine the claimant.
Why Trust Arizona Long-Term Disability Lawyer Paul J. Dombeck
Long-term disability claims are complicated. Unfortunately, the big insurance companies can make it extremely challenging for policyholders to secure the full and fair benefits that may be available under the terms of their plan. Paul J. Dombeck is an experienced Arizona long-term disability attorney. With expertise in how insurance companies actually review cases, Attorney Dombeck is prepared to invest the time and resources to handle your claim the right way. For a free review of your long-term disability claim, please contact our Phoenix law office today.
Schedule a Free Consultation With Our Phoenix Long-Term Disability Lawyer Today
At The Law Office of Paul J. Dombeck, PLLC, our Phoenix long-term disability attorney has the professional experience that policyholders and their families can rely on. If you have any questions about how to deal with the insurance company, we can help. Contact us today for a free, no-obligation case review. With an office in Phoenix, we handle long-term disability cases throughout Arizona, including Maricopa County.
