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Long Term Disability Claims Due to Back Pain



Attorney Stephen JessupAuthor: Attorney Stephen Jessup

One of the most common causes for filing a short or long term disability insurance claim is due to “back pain.” Although this encompasses a wide range of conditions – from disc herniations and bulges to soft tissue disorders and fibromyalgia – insurance companies will evaluate entitlement to benefits as a result of back pain in the same manner regardless of the medical basis for the pain. Complicating the insurance company evaluation further is the fact that the overwhelming majority cases of back pain are due to an unknown etiology, or more simply put – the doctors are not quite sure what the root cause of the pain actually is. In light of this conundrum, insurance companies will often view a claim based on back pain as simply one of “self-report” with no objective evidence to support a level of impairment that would result in disability.

What objective evidence supports a claim due to back pain?

When filing a claim for disability benefits it is imperative to try to provide as much “objective” evidence to support your complaints of pain. The most common forms of objective medical evidence used to diagnosis a person’s complaints of back pain include MRI’s, CT Scans, X-Rays and in instances of radiating pain, EMG and Nerve Conduction Studies. Although having positive test results is not a requirement to receiving disability benefits, positive findings on these tests will greatly assist in the presentation of your claim to an insurance company. This is becoming increasingly true in light of disability insurance policy trends that see the addition to policies of more language that limits claims due to pain to a maximum 24 months of benefits. Many insurance companies now write limitations in policies for “self-reported symptoms” or “neuromuscular, musculoskeletal, soft tissue disorder conditions” that are meant to limit the amount of disability benefits you will receive in the absence of requisite objective medical evidence to support your complaints.

Will my claim be approved if I have positive findings on objective medical tests?

Unfortunately, no. Even with positive findings on objective medical testing, that, in and of itself, will not guarantee that a disability insurance claim will be approved. Insurance company doctors will certainly look to minimize the level of impairment a person experiences regardless of test results. As the experience of pain is completely unique to the individual and there is no way to objectively measure pain, a person’s report of pain will always be based on their subjective complaints. Due to this fact, the insurance company and its doctors will acknowledge findings on MRIs but will often argue that the findings would not support the level of the claimant’s subjective complaints of pain, and in turn would not result in restrictions and limitations that would prevent work.

Objective medical evidence does provide a firm foundation with which to argue why restrictions and limitations relating to work ability are appropriate; however, there still has to be a nexus drawn between the objective medical evidence and establishing and proving functional restrictions and limitations that would prevent you from performing your occupational duties.

What can I do if I don’t have strong objective medical evidence to support my claim?

Regardless of objective medical evidence in your file, one of the most important aspects of establishing a claim for disability due to back pain is the contents and detail in your medical records. Your doctor needs to be accurately and comprehensively documenting your medical records as it relates to your condition. Doctors are not trained to write medical records to satisfy a disability insurance carrier and we often see instances where despite medical evidence and history, a doctor does not document items such as range of motion, bending, the site of the pain, side effects of medication, etc. In the absence of this information in your records an insurance company will assume that you are not having issues related to same.

Another issue that often arises in medical records stems from the automation of many of the records maintained by doctor’s offices. Quite often when entering a record for a patient the record system will have a series of boxes to be checked by the doctor as part of their exam. It is not uncommon for these “checked boxes” to contradict the written notes in the medical record relating to the patient’s complaints. In turn, the insurance companies will often use these contradictions as a basis to undermine a disability claim.

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As disability claims due to back pain are so prominent, disability insurance carriers have many tactics with which to deny a claim for benefits. Knowing what will be needed to put your claim in the best position for success can help nullify these tactics. Proper presentation of your disability insurance claim for back pain or conditions that cause back pain is crucial to your success in having your disability benefits approved. Please feel free to contact our office to discuss how we may be able to assist you.