Beginning in the 1990s, the use of prescription opioids to treat chronic pain sky-rocketed despite concerns about the drug’s addictive properties and long-term risks. Fast-forward 30 years and the Center for Disease Control and Prevention estimates that roughly three million Americans currently suffer from Opioid Use Disorder (OUD), with opioids involved in approximately three-quarters of all overdose deaths.
In addition to costing so many lives, the so-called Opioid Epidemic has also had a significant economic toll on individuals and their families. For many living with OUD, keeping up with work duties becomes untenable due to their condition’s symptoms and resulting functional impairments. Fortunately, disability benefits under an employer-sponsored short- or long-term disability insurance policy may offer some financial security to individuals affected by OUD.
What is Opioid Use Disorder?
OUD is characterized by a profound desire to use opioids—such as heroin, morphine, codeine, fentanyl, and synthetic opioids such as oxycodone—despite social and professional consequences.
To be formally diagnosed with an OUD, an individual must meet the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM 5). Specifically, the DSM 5 defines OUD “as a problematic pattern of opioid use leading to problems or distress,” and the presence of at least two of the following problems occurring within a 12-month period:
• Continued use despite worsening physical or psychological health
• Continued use leading to social and interpersonal consequences
• Decreased social or recreational activities
• Difficulty fulfilling professional duties at school or work
• Excessive time to obtain opioids, or recover from taking them
• More taken than intended
• The individual has cravings
• The individual is unable to decrease the amount used
• Using despite it being physically dangerous settings
• Withdrawal, symptoms of which include abdominal cramps, craving, agitation, diarrhea, pupil dilation, anxiety, elevated blood pressure, sneezing, sweating, elevated heart rate, tearing, shakiness, muscle pain, rhinorrhea, goosebumps, and insomnia.
OUD is often treated with opioid replacement therapy and other medications to deter relapse and treat overdoses. Nonpharmaceutical behavior therapy can also aid treatment, but OUD is generally accepted to be a chronic condition, often including repeating periods of exacerbation and remission.
Is Opioid Use Disorder a Disability?
Whether OUD constitutes a disability depends on the entity making the disability determination.
For short- and long-term disability (STD/LTD) benefits, the definition of disability will be contained in the group insurance policy. Most policies define disability as the inability to perform the material duties of your own occupation due to a medical condition. Given OUD is a medical condition, the inability to perform one’s job duties as a result of this disorder constitutes a disability under most STD and LTD policies.
Contrarily, when it comes to Social Security Disability Insurance (SSDI), substance use disorders (including OUD) are no longer considered a disabling condition on their own. Thus, you cannot receive SSDI benefits for a disability stemming solely from OUD.
As another example, substance use disorders, including OUD, are considered disabilities under the Americans with Disabilities Act, the federal law enacted in 1990 to prohibit discrimination against individuals on the basis of their disability.
Can I Get STD/LTD Benefits for Opioid Use Disorder?
Generally, you can file a claim for STD/LTD benefits for a disability resulting from OUD. In addition to meeting your plan’s definition of disability, there are additional requirements that you must meet in order to be eligible to receive STD/LTD benefits. These requirements usually include:
• You Must Be Under the Care of a Physician
Most plans require that you continue to regularly treat with a medical provider and comply with their reasonable treatment recommendations. If you fail to do so, your benefits may be denied.
• You Must Provide Proof of Continued Disability.
Even after your STD/LTD claim is approved, you will be required to provide proof of your ongoing disability. This is usually satisfied by providing updated medical records and/or having your treating medical providers complete updated disability paperwork confirming that you remain unable to work.
• Your Earnings (if any) Must Be Below the Plan’s Threshold Amount.
In most STD/LTD plans, a claimant is allowed to work in a limited, part-time capacity while also receiving STD/LTD benefits. However, if you earn more than a certain amount (usually somewhere between 60 to 80 percent of your pre-disability earnings), you will no longer be eligible to receive STD/LTD benefits.
Additionally, if you are filing an STD/LTD claim for OUD, you should also be aware of whether your plan has an exclusion for disabilities due to “intentionally self-inflicted injuries.” This is important because the insurer may try to deny your claim on the basis that disability due to OUD is “intentionally self-inflicted.” In reality, OUD should not fall within this exclusion. Courts distinguish that while an act (such as using opioids) may be intentional, the result of the act (such as becoming disabled) is not always intentional.
Finally, if you are newly covered under your employer’s LTD policy, you will also want to pay attention the policy’s pre-existing condition exclusion. Generally, if you become disabled within one year of your effective date of LTD coverage, the insurer will review your claim to see if your disability is due to a pre-existing condition, in which case benefits would not be payable. A pre-existing condition is a condition for which you have obtained medical treatment or services within a certain amount of time (usually three months) prior to becoming covered under the LTD policy. If, however, you have been covered under the LTD plan for more than one year, the exclusion for pre-existing conditions does not normally apply.
Are Disability Claims for Opioid Use Disorder Treated Differently?
Unfortunately, most LTD policies treat disabilities due to substance use disorders and mental health conditions differently than disabilities due to physical medical conditions. Specifically, these policies usually have a 24-month “mental illness limitation” that limits the payment of benefits to two years for individuals whose disability is caused by a mental health condition or substance use disorder. I comparison, the same policy usually pays benefits until age 65 or longer for an individual whose disability is caused by a physical health condition.
There are a few exceptions to this rule:
• If you are confined to a hospital due to your OUD at the end of the 24-month period, the limitation will not apply while you are continuously confined.
• If your OUD occurred because of your physical health issues, the insurance company should treat this as a physical health claim so long as the physical condition continues to prevent you from working. For example, if you became disabled due to a back injury and subsequently developed debilitating OUD, your claim should not be subject to the mental health limitation if your back injury continues to prevent you from working.
How Does Stigma Impact Individuals with STD/LTD Claims?
Though we have come a long way in terms of reducing the stigma surrounding substance use disorders, we still have a long way to go and stigmatization remains significant for individuals living with OUD. Indeed, there remains the harmful misconception that individuals with substance use disorders have a character flaw or became dependent on opioids due to their moral failures. This misbelief discourages individuals living with OUD from seeking the help they need, including filing claims for STD/LTD benefits.
Research shows that we reduce stigmatization of mental illness and substance use disorders by drawing comparisons between physical and mental illness. We would never question someone with cancer filing a claim for STD/LTD benefits, and the same should be true for someone with OUD. These policies exist for a very important reason—to provide financial security to individuals facing debilitating medical conditions so they can focus on what really matters, getting healthy.
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