The Employee Retirement Income Security Act of 1974 (ERISA) lays out specific requirements for qualifying disability plans offered by private employers. If you have disability insurance through your employer, there is a great likelihood that it must comply with ERISA. ERISA protects you as a plan participant; however, the insurance companies still have great leeway in making requirements for qualification of plan benefits. It is important that you understand how to obtain benefits from your plan so that you gather and provide the insurance company with the information necessary.
Proving You Are Disabled
The biggest challenge in applying for disability benefits is proving that you are disabled according to your insurance company’s requirements. Although every ERISA disability plan must comply with the law, they are given great leeway in establishing requirements for proving disability. Some of the elements you must prove include:
- Onset of disability date
- Last day worked (LDW)
- Medical condition(s)
- Inability to perform job duties
Each of these elements require distinct evidence, some of which can be complicated. Although your insurance company will claim to be on your side, their interest is always to handle claims quickly and for as little money as possible. You must prove that you are disabled despite the insurance company’s attempts to show that you can still perform your job duties.
What is Objective Medical Evidence?
In order to prove that you are disabled, you must provide objective medical evidence. Objective evidence is that which can be shown through facts and observable measurements. This contrasts with subjective evidence, such as claims of pain or fatigue, which are dependent upon your personal opinion of the situation. Objective medical evidence can only be obtained from a licensed medical provider.
Date of Onset of Your Disability
Proving your onset of disability date can be done with office notes from your doctor or other objective evidence that provides more than a statement about your symptoms. Your doctor will often provide a reliable medical opinion in his or her records that states you are unable to do your job as of a certain date. That opinion will be based on other objective medical evidence that must also be submitted. You should be able to find a specific date within the doctor’s notes that can be pointed to as an onset date. If you are unable to do that, you must have other medical evidence that shows when your medical conditions became so severe that you became unable to perform your job duties. This may require a significant amount of objective medical evidence. You may also provide your doctor with that evidence so that your doctor can provide an opinion about when you became disabled in the past based on that objective evidence. Regardless, you must have a specific date of onset of disability based on medical information.
The Date of Your Last Day You Worked
Your last date worked is based on the last date you were able to work according to your onset of disability. Thus, you must only provide to the insurance company evidence that you stopped working on a specific date. If you tried to continue working past your onset of disability date, you must provide an explanation about why you attempted to continue work as well as witness testimony that your work was unacceptable past that date. Just like with an onset of disability date, you should have a specific date for your last day worked.
Existence of medical conditions and their severity must be shown through objective medical evidence. Whether you have physical or mental conditions, there are objective tests that can be used to prove you have a disabling condition. Common objective tests include:
- Radiological tests (x-rays, CAT scans, MRIs, etc.)
- Laboratory tests (bloodwork, bone marrow testing, etc.)
- Psychological tests conducted by licensed medical professionals
There are objective tests to verify the existence of all medical conditions. Although some of those tests may not provide extensive information, when combined with office notes and reliable medical opinions, objective tests can provide enough evidence to insurance companies to prove that a disabling condition exists.
Performance of Job Duties
Your ability to perform job duties will depend on your doctor’s assessment of the severity of your condition. Your doctor should conduct objective tests and make a reliable opinion regarding what you are able to do according to your conditions. If you are unable to sit for longer than an hour at a time, your doctor may opine that you cannot perform the duties of your desk job. Your doctor may perform a functional capacity exam in order to determine exactly what you can and cannot do according to the severity of your conditions.
What if You Don’t Have Enough Objective Medical Evidence?
Your insurance company may deny your claim or send you to an independent doctor if you do not have enough objective medical evidence to prove that you are disabled. It is important that you comply with all of your insurance company’s requests by the deadlines they specify. If they send you to an additional doctor, you must fully cooperate. Otherwise, your claim will be denied.
Our experienced ERISA disability attorneys at Wilkinson & Magruder, LLP are available to help gather your objective medical evidence to support your claim for ERISA disability benefits. Contact us today at (706) 550-6699.