Disability insurance companies base their claim decisions on the claimant’s medical restrictions and limitations. “Restrictions” are what some cannot do as determined by their doctor, while “limitations’ are what someone is limited in doing. In the absence of restrictions or limitations, there is no “disability” as defined by the policy.

The issue is even more complex because of the uniqueness of disability insurance. Unlike other types of insurance, claimants have three discrete issues they face in obtaining benefits – legal, medical, and vocational. The legal issue relates to the terms of a policy – how it defines disability and whether other provisions might disqualify someone from receiving benefits such as a pre-existing condition exclusion. The medical component relates to a doctor’s opinion as to the condition or conditions causing disability, the claimant’s symptoms, and how those issues affect someone’s ability to work. However, neither a diagnosis nor the presence of diagnosed symptoms is enough to establish a disability. That is where the vocational component comes in. The condition and its symptoms have to cause restrictions and/or limitations that would preclude someone from working at a specific occupation or any occupation. And to make matters even more complicated, in evaluating whether someone is unable to perform the duties of their regular occupation, depending on the physical or mental/cognitive requirements of the occupation, mild restrictions or limitations may either be consequential or immaterial. For example, a mild limitation caused by a hand tremor could be job-killing for a surgeon executive, while the same limitation would be relatively inconsequential for an attorney.

Exertional Restrictions and Limitations

There are two categories of restrictions and limitations – exertional and non-exertional. Musculoskeletal, cardiac, and neurological impairments are likely to cause exertional restrictions and limitations. Those restrictions and limitations affect someone’s ability to sit, stand, walk, carry, and perform physical activities. Some jobs, such as that of a paramedic or firefighter, have significant exertional demands, while many professional and executive jobs are considered sedentary in nature. A sedentary job involves sitting for most of the workday and lifting ten pounds or less.

Doctors may tell cardiac patients never to lift more than twenty pounds. Or orthopedic surgeons may tell a patient who has undergone back surgery not to bend at the waist. Those instructions would constitute restrictions. However, rather than instructing a patient not to lift more than a certain weight, the doctor might tell the patient that it is recommended they not do so. That would be a limitation. Doctors frequently tell patients that they should limit the time they stand, the distance they walk at any given time, or how frequently they may bend or squat.

None-Exertional Limitations

Non-exertional limitations relate to seeing, hearing, and speaking and can also result from conditions that cause pain and fatigue without specific radiologic or other medical test findings. There really are no non-exertional restrictions, although someone who is blind is obviously restricted from seeing. However, non-exertional limitations are common. A chronic migraine headache sufferer may be “limited” from working. People with severe gastrointestinal conditions such as ulcerative colitis may only be limited to working only at a job where they would be able to have immediate access to a nearby bathroom. That limitation might be sufficient to permit some to work; however, such a limitation would likely not be sufficient to permit an obstetrician to work since their work cannot be disrupted in mid-delivery. Someone who suffers from chronic pain may have limitations in the ability to concentrate and pay attention that could be devastating to most executives or professionals. Further, although pain might be mitigated with medication, the medication might produce sedative effects that themselves would preclude working.

Can Restrictions and Limitations Be Measured?

There are no truly objective means of measuring restrictions and limitations, especially non-exertional limitations. Tests such as functional capacity evaluations, which physical or occupational therapists perform, can often be informative as to limitations based on observed measurements of performance. Cardiopulmonary exercise testing may also be useful in assessing physical stamina. Sleep studies can also provide objective support for complaints of excessive daytime sleepiness. Obviously, hearing and vision testing, and even pulmonary function testing, can establish seeing, hearing, and breathing limitations that may not be correctable with hearing aids, eyeglasses, or medication. However, many conditions such as chronic headaches, dizziness, or fatigue can be difficult to assess and determine limitations.

If the claimant’s condition interferes with cognitive functioning, irrespective of whether the condition is behavioral health-related, neuropsychological testing is the gold standard for evaluating limitations. Such tests examine intelligence, memory, executive functioning, concentration, attention, and other issues and provide valuable evidence proving specific limitations in critical areas of mental functioning. A doctor who experiences a traumatic brain injury and has neuropsychological test results showing impairment or even very low average scores would not be capable of safely treating patients.

How Do Disability Insurance Companies Evaluate Restrictions and Limitations?

Generally, medical records are not created for the purpose of establishing disability, so it can be challenging for insurance companies to accurately assess a claimant’s restrictions and/or limitations. However, some tests produce so obvious results that it is usually fairly easy to discern restrictions and limitations. Cardiac tests that show markedly reduced left ventricular ejection fractions would account for reduced functional capacity. MRI, CT, and x-ray scans can also show musculoskeletal conditions that would have obvious functional implications. Likewise, neurological testing may be revealing of limitations in exertional capacity and manual dexterity needed to utilize a computer and keyboard.

Often, however, disability insurance companies need to utilize vocational rehabilitation consultants to better understand the requirements of particular occupations and help make a comparison between examination and test findings and the ability of a claimant to perform a specific job. Doctors usually lack such qualifications. Indeed, even occupational medicine physicians are untrained in vocational assessments. Their title just means they are trained to evaluate and treat occupational injuries and illnesses.

How Do I Challenge an Unfavorable Insurance Company Assessment of My Restrictions and Limitations

Just because a treating doctor describes a patient as too limited to work, that does not mean an insurance company is going to accept that opinion. It is also not uncommon to see insurers rely on opinions obtained from doctors hired to review claims that may agree with the treating doctors’ stated restrictions and limitations yet report they see no obstacle to the claimant’s ability to work. Many such opinions fail to take into consideration whether the insurance policy’s disability definition is occupation-specific. Such opinions are faulty because the ability to work at a generic “job” does not mean someone could perform the duties of their occupation.

When a claimant for benefits runs into a situation like this, they should immediately seek assistance from a disability insurance benefits attorney who is familiar with how restrictions and limitations affect employability and who can assist in clarifying the issues and proving the case. There may be a need for additional testing or retention of a vocational consultant to offer an opinion on the claimant’s behalf. The failure to obtain such evidence could very easily doom a valid claim. Many courts will not consider new evidence that could have been presented during the claim and appeal process. Thus, establishing restrictions and limitations relevant to particular occupations is where experience and expertise matter.

Related Articles

ERISA Ruling Reinforces Claimant Right To Know Denial Basis

ERISA Ruling Reinforces Claimant Right To Know Denial Basis

One of the unique aspects of litigation under the Employee Retirement Income Security Act is that most courts limit the scope of their review to the claim record compiled during the course of the claim and prelitigation appeals and will not address new evidence that was not previously considered. […]

Congress Must Ban Discretionary Clauses In ERISA Plans

Congress Must Ban Discretionary Clauses In ERISA Plans

A recent Law360 guest article argued that discretionary clauses in employee benefit plans governed by the Employee Retirement Income Security Act serve a valuable function, and that if efforts to prohibit their inclusion are successful, the statute would be undermined […]