Cardiac Conditions and Disability Insurance – A Claimant’s Guide

In the area of cardiac conditions and disability insurance, it is important to note that despite advances in cardiac care and treatment, more than one in three American adults suffer from cardiovascular disease; and more than half are under age 60 (See the National Library of Medicine “Cardiovascular Disability Trends”).  Thus, cardiovascular disease is prevalent; and if severe enough, it can result in disability.

A diagnosis alone is not a disability; however.  In order for someone suffering from cardiovascular disease to qualify for disability insurance benefits, a claimant needs to show functional impairment resulting from their condition.

Identifying Disabling Symptoms of Cardiac Conditions

Typical cardiovascular symptoms that are associated with disability include:

• Shortness of breath, often abbreviated in medical records as “DOE” (dyspnea on exertion). Shortness of breath at rest is even more serious and likely to result in an award of benefits
• Chest pain. As with shortness of breath, someone who experiences chest pain (angina) may qualify for benefits; and the symptom is viewed as even more serious if symptoms occur while at rest
• Cardiac conditions can cause fainting or near-fainting episodes that would pose a danger in the workplace
• Cardiovascular conditions alone may cause fatigue, or medications used to treat such conditions may result in profound fatigue that makes it impossible to get through the work day
• Swelling of the hands or feet – this is known as edema and is a sign the heart is not working properly

Common Cardiac Conditions Leading to Disability Claims

 There are many cardiovascular conditions that can result in disability.   The most common are:

• Congestive heart failure – this occurs when the heart is unable to pump blood efficiently. It may be due to a variety of causes, including damage to heart muscle as the result of a heart attack.
• Ischemic heart disease – this means there is an inadequate blood supply to the heart, typically caused by narrowed cardiac arteries (stenosis) and is treated with the insertion of stents or may even require bypass grafting
• Arrythmias – these are irregularities in the patient’s heartbeat. If the heart beats too fast, too slowly, or irregularly, it can potentially result in death

While there are treatments for all these conditions, treatment is not always successful, and the underlying condition may result in permanent impairment.

Documenting Cardiovascular Disease for Disability Insurance

There are many different types of tests available to diagnose cardiovascular disease.  Many cardiovascular illnesses are diagnosed with treadmill stress tests and the testing may involve the use of a radioactive dye to better visualize the heart. Magnetic resonance imaging is also useful in evaluating heart disease, as are echocardiograms, which use ultrasound to visualize the heart at motion and determine whether the heart valves are properly opening and closing. Ultrasound testing can also diagnose peripheral vascular disease. In addition, computerized tomography (CT) is often used to look at the blood vessels and see whether blood is properly flowing through each vessel, although it may sometimes be necessary to perform angiography, which requires a small incision and uses a catheter to explore the heart vessels and insert stents if blockage is found.

Evaluating Disability

The best source of standardized measures that would establish disability due to cardiovascular disease are the criteria published by the Social Security Administration (SSA).  Those SSA criteria are currently undergoing revision to bring them up to date, but the Social Security criteria are extremely stringent; and if someone meets those criteria, they are likely to qualify for disability benefits both from private disability insurers as well as from SSA.

Another commonly used source for establishing disability is a publication of the American Medical Association known as the Guides to the Evaluation of Permanent Impairment.  That publication utilizes criteria developed by the New York Heart Association that classifies heart failure into 4 categories –

• Class 1 – no symptoms or limitations on physical activity
• Class 2 – mild symptoms such as shortness of breath during ordinary activity
• Class 3 – marked limitation of activities due to cardiovascular symptoms such as the inability to walk short distances, although there are generally no symptoms at rest
• Class 4 – severe limitations due to cardiovascular symptoms that occur both at rest and while performing physical activities

A rating in the first two classes will generally not support a disability claim, while being rated Class 3 or 4 will generally support a finding of disabled.

Stress and Cardiovascular Disability

 The association between stress and cardiovascular disease is well known and has been recognized in court rulings involving cardiac illness and disability.  However, the rulings have not been uniformly favorable to claimants. If symptoms are well controlled at rest or even while performing ordinary activities, the risk of death or severe complications due to work stress may or may not be enough to lead to a favorable disability determination.  However, several courts have pointed out that it would be improper for disability insurance companies to play a form of “benefits Russian roulette” and wait and see if complications result as a condition of approving benefits.

Preparing and Applying for a Disability Claim with Cardiac Conditions

 Anyone suffering from cardiovascular illness who is contemplating applying for disability benefits needs to do two things before applying:

• First, make sure that all testing recommended by the treating doctor has been performed. Claims are more likely to be approved if there is objective documentation of cardiac abnormalities such as a echocardiogram showing a markedly reduced left ventricular ejection fraction.
• Second, the claimant needs to be certain that they have the support of their treating doctor before applying for benefits.
• Third, it is important consideration is that if someone has been working while suffering from cardiovascular disease, they will likely need to establish what has changed in their condition to justify a cessation of work.
• Finally, it is important for disability benefit claimants to understand that just because their doctor says they are disabled does not guarantee that the insurance company will agree.

While attorney representation is usually not necessary before applying for benefits, it may be advisable to consult with an attorney before applying for further guidance on pitfalls and proactive steps that may be taken to head off a potential denial.  However, if disability benefits are denied, it is essential for claimants to be represented by a knowledgeable and experienced attorney who is familiar both with disability insurance law, including ERISA law if benefits are from an employer-sponsored group long-term disability plan, as well as familiar with what is needed to prove disability based on cardiovascular illness.

DeBofsky Law fulfills those criteria. We specialize in all types of disabling conditions and disability insurance claims, including cardiac conditions, offering expert legal support and guidance. With decades of experience and a track record of proven success in court, DeBofsky Law is equipped to meet your needs.