Self reported symptoms limitation
It is common practice for disability insurance companies to find ways to limit the amout of money they have to pay to claimaints. One of the ways they attempt to limit their exposure is to add limitations into their policies that require the claimant to provide “objective evidence” to prove they have certain conditions such as fibromyalgia or chronic fatigue syndrome. The glitch is that it is impossible to provide “objective evidence” for these conditions since these tests do not exist. Recently, courts have ruled that insurance companies cannot require such objective evidence for these conditions as this is an unfair requirement as it is impossilbe to provide.
Mental nervous limitation in disability policy
It is pretty well known in the disability insurance arena that group disability plans commonly contain a 24 month limitation for mental nervous conditions. If a policy holder makes a claim for benefits as a result of depression, anxiety, post tramatic stress disorder or any other mental nervous conditon, the policy holder is limited to 24 months of benefits.
Limitation for any neurological or muscoskeletal or soft tissue claim
In addition to the mental nervous limitaiton, several insurance companies are also adding limitations for physical conditions such as injuries or disorders of the spinal cord, extremities and other soft-tissue disorders. If a claimaint has a spinal cord inury which prevents him or her from being able to sit, stand or walk for prolonged periods of time as well as lift bend or stoop, and as a result are permanaenly disabled and unable to perform the material and substantial duties of their occupation, he or she may only be able to collect disability benefits for 24 months. This is devastating to many policy holders since physically they are unable to work, their treating physicans support their inability to work, but regardless of all the medical support, their policy only allow benefits to be paid for a maximum of 24 months.
What does this limiting language look like?
An example of some limiting language that may be contained in your long-term diability policy is as follws:
For Disability Due to Mental or Nervous Disorders or Diseases, Neuromusculoskeletal and Soft Tissue Disorder, Chronic Fatigue Syndrome and related conditions.
If You are Disabled due to one or more of the following, We will limit Your Disability Benefits to a per occurrence maximul equal to the lesser of:
- 24 months; or
- The Maximum Benefit Period
2. Neuromusculoskeletal and soft tissue disorder including, but not limited to, any disease or disorder of the spine or extremities and their surrounding soft tissue; including sprains and strains of joints and adjacent muscles, unless the Disability has objective evidence of:
- Seropositive Arthritis;
- Spinal Tumors, malignancy, or Vascular Malformations;
- Traumatic Spinal Cord Necrosis; or
- Myopathies; or
3. Chronic fatigue syndrome and related conditions.
There are some exceptions to the above limitations; however, unless the claimant can provide “objective evidence” of the exceptions, the insurance company will not extend benefits beyond 24 months. Even if a claimant undergoes an MRI that reveals herniations or bulging discs that require spinal surgery, the policy will still limit benefits to 24 months. The only way to exceed the 24 month limitation is to provide objective evidence of either Seropositive Arthritis; Spinal Tumors, malignancy, Vascular Malformations; Radiculopathies; Myelopathies; Traumatic Spinal Cord Necrosis; or Myopathies. These exceptions can be defined as follows:
- Seropositive Arthritis: An inflammatory disease of the joints supported by clinical findings of arthritis plus positive serological tests for connective tissue disease.
- Spinal: Components of the bony spine or spinal cord.
- Tumors: Abnormal growths which may be malignant or benign.
- Vascular Malformations: Abnormal development of blood vessels.
- Radiculopathies: Disease of the peripheral nerve roots supported by objective clinical findings of nerve pathology.
- Myelopathies: Disease of the spinal cord supported by objective clinical findings of spinal cord pathology.
- Traumatic Spinal Cord Necrosis: Injury or disease of the spinal cord resulting from traumatic injury with resultant paralysis.
- Myopathies: means disease of the skeletal muscle supported by clinical, histological, biochemical and/or electrodiagnostic findings.
3. Chronic fatigue syndrome and related conditions.
In no event will Monthly Benefits be payable longer than the Maximum
How Can I Help Ensure That My Claim Extends Beyond 24 Months?
It is imperative to make sure that your treating physicians are aware of the limitations in your policy so they can order the appropriate tests to determine whether one of the many exceptions applies to you. A claimant may fall under one of these exceptions, but if their physician fails to order to appropriate tests the record will lack objective proof and their benefits will be terminated after 24 months. Timing is also very important, since the claimant may test positive for one or more of the above exceptions after the administrative record is closed and as a result will not be permitted to add these result to the record. This can be devastating to their claim as a judge will not be permitted to consider any new information.
Further reading: Are There Exceptions to the Mental Illness Limitation in a Disability Insurance Policy?
Our disability attorneys have helped hundreds of clients to present claims that would not be limited by the 24 month limitation. Contact us for a free consultation to discuss your claim.