A Comprehensive Guide to Understanding Arthritis and Joint Disease Disability Insurance Claims

According to the Centers of Disease Control and Prevention (CDC), the leading cause of disability in the U.S. is arthritis. Arthritis is a name given to multiple conditions that result in joint swelling, inflammation, and stiffness, resulting in pain and dysfunction such as an ability to walk or perform job duties requiring hand use. The CDC reports that over 24 million Americans are limited in their everyday activities by arthritis and over 58 million Americans suffer from arthritis in one form or another. Out of that number, 10 million Americans report symptoms of anxiety or depression, which worsens their arthritis symptoms and makes treatment more difficult.

Are There Different Kinds of Arthritis or Joint Condition?

The most common form of arthritis is osteoarthritis, which results from trauma or wear and tear on the joints. Another type of arthritis is rheumatoid arthritis, which is an autoimmune condition that can cause swelling and changes in the bone structure of feet, hands, and other joints in the body. Psoriatic arthritis is yet another autoimmune disorder that affects the joints of the body, along with ankylosing spondylitis, a condition that causes joints to fuse together due to the severity of the inflammation. Ankylosing spondylitis most often affects the spine and hips.

Can Arthritis Be Cured?

Arthritis is a chronic and degenerative disorder, although medications such as Humira®, Embrel®, and a host of other drugs that fall under the classification of TNF (tissue necrosis factor) inhibitors are used to reduce inflammation. However, there is no cure for arthritis. Doctors can only treat the pain and inflammation caused by arthritis, although arthritic pain and inflammation may become so intractable that it is beyond effective treatment.

When Does Arthritis and Degenerative Joint Disease Become a Disability?

Arthritis sufferers may need to seek disability benefits if their arthritis and degenerative joint disease keeps them from working on a regular basis at their own job or prevent them from working at any job. For example, a surgeon whose hands become too stiff and painful to safely perform surgery may need to seek disability benefits. Or a worker who needs to be on their feet for extended periods of time during the work day but cannot do so due to severe pain and discomfort may also be disabled.

How Do I Prove Disability Due to Arthritis?

While pain cannot be measured, the severity of joint damage due to arthritis is visible on x-rays and MRI scans. Moreover, inflammation caused by rheumatoid and psoriatic arthritis is often detectable in blood tests which may show an elevated c-reactive protein level indicative of inflammation or a high erythrocyte sedimentation rate. Ankylosing spondylitis is usually established by the presence of the HLA-B27 antigen. However, some people exhibit clinical signs of rheumatoid arthritis with negative blood test results. That does not mean they do not have rheumatoid arthritis, though, and subsequent blood tests may show positive results.

What Can I Expect Will Happen After Submitting a Claim for Arthritis Disability Benefits?

When a disability claim is submitted, insurance companies require that the claim be accompanying by an attending physician’s statement certifying the claimant’s disability. Insurance companies will almost always ask for additional evidence to demonstrated proof of loss, though. For example, it is common for the insurance company to interview each claimant to learn how their symptoms have impacted their ability to work. The insurance company will also request copies of treatment records, including imaging studies, blood test results, and other relevant records such as physical therapy notes.

It is possible that the insurance company may request that a claimant attend an examination with a physician of its choosing; and if the wording of the policy allows, may also request the insured to attend a functional capacity evaluation, a test lasting several hours that requires the claimant to perform a number of physical tasks aimed at determining the claimant’s ability to walk, lift, grip, bend, or perform other tasks. Surveillance is also possible, although it is impermissible for an insurer to use a high-powered lens to peer into the claimant’s home. Social media posts may also be investigated to see whether a claimant is engaging in activities inconsistent with claims made to the insurer.

Related Article: 5 Steps to Applying for Long Term Disability Benefits?

What Should I Do if My Claim Is Denied?

When a claim is denied, claimants are typically invited to appeal the claim denial; although an appeal is mandatory for most claims brought under employer-sponsored group disability insurance policies as a condition of bringing a lawsuit against the insurance company. Although there is no obligation to utilize the services of an attorney in appealing an unfavorable determination, it is advisable for claimants to hire a knowledgeable and experienced attorney to do so. Disability claims are complex and involve legal, medical, and vocational issues. In many instances, a claimant’s failure to present evidence and possibly even the failure to raise issues might severely lessen a claimant’s chances of success in court should the appeal be unsuccessful. Most courts will not permit the introduction of new evidence once the claim appeal is over.

An attorney who is knowledgeable and experienced in handling disability claims will know how to identify the weaknesses in a claim denial and muster a successful counterattack. No two cases are alike, and a diagnosis alone is never enough to prove disability. Nor is a letter from a doctor stating their patient is “disabled” usually enough to convince an insurance company. It takes the experience gained from representing others who have received similar diagnoses and the knowledge to tailor an appeal to the specifics of the claimant’s condition, their occupation, and other factors that distinguish each case which results in success in overturning a claim denial.

Not every appeal is successful, though, and litigation may be necessary. Depending on the egregiousness of a claim denial, and whether the claim is governed by the Employee Retirement Income Security Act (ERISA), in addition to the claim for benefits due, there may also be a possibility of suing the insurance company for damages and penalties. A knowledgeable attorney experienced in handling disability claims lawsuits is critical to success in court.

The lawyers at DeBofsky Law, Ltd. have both the necessary knowledge of disability benefit issues and extensive experience in handling disability benefit claim appeals and lawsuits should you find yourself in need of their services.