What medical criteria does a disability company rely upon in order to determine if a claimant qualifies for a specific disabling condition?

Disability insurance companies will always say that “diagnosis does not equal disability”. This is a true statement in many cases, as there are people every day that are diagnosed with a medical condition yet they are still able to work. The difficulty develops when a person is claiming disability and the disability company is challenging the claimant’s diagnosis and medical condition.

A medical condition which is recognized by the medical community has a general set of guidelines for diagnosis of the condition. For example, if a claimant is diagnosed with depression, then the disability company will expect the claimant to satisfy the criteria for depression as stated in the DSMV-4. There are several medical conditions which are disputed within the medical community, such as Lyme Disease, Chemical Sensitivity disorder, Fibromyalgia, Chronic Fatigue and Headache disorders. Different medical organizations and institutions have created different medical criteria for the same medical condition. Lyme disease is a perfect example of disputed criteria and treatment for the same condition. Despite the dispute among medical doctors, these are all disabling medical conditions.

The disability insurance companies will often subscribe to the least favorable standards for a medical condition or make a claimant satisfy a medical threshold which is almost impossible to achieve. When presenting a disability claim it is more important to have your complaints, symptoms and restrictions diagnosed and documented, than it would be to have an exact diagnosis. Medicine is not an exact science and doctors sometimes give a patient a diagnosis because they have excluded all other possible causes of patient’s symptoms. Regardless of the diagnosis the claimant’s inability to work as result of there symptoms is what must be proved.

Comments (10)

  • Gwen,

    Filing for unemployment is a huge risk to your LTD claim. First and foremost, when applying for unemployment you assert you are ready, willing and able to work. This will be in contrast to what you are holding out to your LTD company. Additionally, your policy may not allow you to work while on disability. Furthermore, if you do receive unemployment, it would be a direct offset of your LTD benefit so the net effect of receiving it would be zero.

    Stephen Jessup Jan 13, 2016  #10

  • I was approved for LTD through Lincoln financial on 10/15 and been LOA since 04/15 I was let go from my employer on 12/15 because they could not keep holding my position I was told I can file for unemployment in Florida. but doctors have not cleared me to return to work on my LTD policy states you are approved for 24 months on your specific job can I file for unemployment without losing my LTD.

    Gwen Jan 13, 2016  #9

  • Gabriele,

    You will need to appeal the denial of the final month of benefits. If you have not done so already please feel free to contact our office to discuss how we may be able to assist you.

    Stephen Jessup Oct 7, 2015  #8

  • On 8-31-15 I was admitted to hospital with chest pain. I am also Type one diabetic uncontrolled. Due to pancreatic cancer. I also been diagnosed with depressions which I take medication for it just recently. Well I applied for short term disability, and was told that my disability type one diabetic is pre existing and depressions everybody has and people still able to go work , same with my diabetes. I have a note where the doctor require for me to stay out to the end of October but Aetna short term disability only pay me from 9-12-15 -9-25-15, because of pain in my neck. This was not my first diagnosis, which was, chest pain unspecified, uncontrolled diabetic, depressions. I believe I have benn discriminated against my disability under Ada . What are my options, because as of now Aetna disability closed my case.

    I live in Florida.

    Gabriele Z. Oct 6, 2015  #7

  • Tammy,

    That is the million dollar question in most disability claims. If your policy is a group provided ERISA based policy there is no financial disincentive to the carriers to act in such a way due to the fact that if you ever have to go to trial and you win, the only thing the carrier will owe are the back benefits due (sometimes even less). Without the fear of extra-contractual damages many carriers seem to deny at will to see who will fight them.

    Stephen Jessup Aug 29, 2013  #6

  • Curious – I was denied my disability, I am now appealing. Waiting on a date. I went back and forth with them like going to their doctors, getting more information on my physical well being with my doctors. In April 2013 I was working part time and got fired due too my disability, they told me my past jobs I probably still can do. The issues I have started 2012; I was hospitalised for pheunima, was in 1 week. I came home, went back to emergency cause I couldn’t breathe, they had do drain fluid from my heart, yet another week in hospital. After all that I was diagnosed with RA which attacked my lungs and heart, then bones. My DX consist of perocarditits, anemia, asthma, depression, ADHD, migranes, memory issues, bad swelling, sinusitis, rapid heart rate, hosomotos, DZ {another autoimmune), panic attacks. Why was I denied?

    Tammy Aug 28, 2013  #5

  • Bobby,

    With proper medical support stating you cannot work, then you have a good chance of being approved. Obviously you need an experienced advocate to handle your hearing. We can recommend someone if you need assistance.

    Gregory Dell May 2, 2013  #4

  • I am waiting for my ALJ hearing, but I have been diagnosed with additional conditions. I have Epilepsy (Gran Mal Seizures), about 1 a month, Type 1 Diabetes, COPD, Asthma, Diastolic Heart Failure, Sleep Apnea, Diabetic Retinapathy, Diabetic Neaurapathy, and Depression, what is the likelihood of getting approved for SSDI?

    Bobby May 1, 2013  #3

  • Nicole,

    The person you spoke to is completely wrong. Any arthoscopy is a surgery.

    Gregory Dell Mar 1, 2013  #2

  • I filed for my short term disability on 2/14. The waiting period is for 15 days. I had left knee arthoscopy done to fix my knee. The lady was very rude to me today and told me that arthoscopy is not surgery and being the way she was they will probably deny me. I am a nurse and know it is a surgical procedure. Do I have any grounds to stand on?

    Nicole Brokaw Feb 28, 2013  #1

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Craig (California)

Cesar and Michal helped me through my case against Prudential. That only touches the surface. I suffered a bad injury which made me a challenge as I often didn’t recall what was said and to whom.

Cesar took the leap of faith to help me but he didn’t treat me like a client but more as if I was part of your family. I don’t know how you were able to get transform the team to have such a great attitude but by far I must say I am treated well from the moment I called, retained your firm it helped me through the minute I faced IME’s. Cesar demonstrates empathy and cares for his clients. I know that I made the right decision to select your firm and am fortunate that firms such as yours are around to help go up against big companies.

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The first and most important matter you have at hand is to take care of your health and let your retained lawyers handle the information needed to not only be approved for long term disability but also to make sure that your claim is managed for the duration of your disability. The disability is a matter that may last a lifetime.

A thorough online yelp review was held prior to conversations with Cesar Gavidia Esq. and Michal Mizrahi from the firm of Dell & Schaefer. I decided to retain them to handle my disability claim. The law-firm has an elaborate web page that demonstrates their ability to go up against all the largest insurance with a stellar track record.

The ERISA law is complex and if you decide to battle the insurance company without representation the odds will be stacked against you. An insurance company has one goal alone and that is to generate profits. The representation of Cesar Gavidia Esq. and Michal Mizrahi were responsible for the successful appeal and approval of my case.

An insurance company typically will deny or delay the claim as the penalty for denial or delay is non-existent. In my case, I was prepared with retained council Cesar Gavidia Esq and Michal Mizrahi who prepared and submitted the ERISA appeal. The document was complete and included information to demonstrate that I was disabled and overturned a previous denial from Prudential.

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I never met Cesar Gavidia Esq. or Michal Mizrahi in person but I consider them my friends versus just attorneys that have been hired.

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