When it comes to long-term disability (LTD) claims, having a diagnosed medical condition is only part of the story. Many claimants are surprised to learn that simply proving you have a medical condition, and even having the support of a treating provider as well, does not guarantee an approval of a claim. What can make or break a case to insurers and courts is whether you can objectively prove how your condition limits your ability to work. This distinction between proving your condition and proving your limitations often becomes the decisive factor in benefit denials.
What Courts Say About Objective Evidence in LTD Claims
Recent federal court decisions have clarified the role of objective medical evidence in LTD cases under ERISA:
- Courts recognize that some symptoms are not objectively measurable – such as pain and fatigue. In this scenario, it is unreasonable to require evidence that cannot be produced. At the same time, courts recognize that insurers are permitted to require objective evidence of functional limitations, even for symptoms that are not objectively measurable. Even if a claimant cannot provide objective proof that they feel pain or fatigue (because such proof doesn’t exist), they can and should provide objective evidence demonstrating how their pain and fatigue limits their functional abilities, such as through an FCE.
- While insurers may require objective medical evidence, insurers also cannot dismiss credible, consistent symptom reports solely because they are subjective. The totality of the medical record, including subjective reports and treating physicians’ assessments, must be considered. On the flip side, a court may uphold an insurer’s dismissal of a claimant’s subjective reports if they are unsupported by available objective evidence and inconsistent with other parts of the record.
- If claimants refuse reasonable requests for functional or cognitive testing, it weakens their case. Conversely, normal test results can undermine claims if those tests specifically assess the claimed limitations. For example, a claimant with cognitive complaints may undergo neuropsychological testing. If results show normal function, an insurer may reasonably question the extent of claimed cognitive limitations. On the other hand, if tests show measurable deficits consistent with reported symptoms, those results strongly support the claim.
Examples of Objective Medical Evidence to Support LTD Claims
If you are applying for benefits or appealing a denial, consider the following types of objective evidence that can strengthen your case:
- Functional Capacity Evaluations (FCEs): FCEs are physical therapy assessments that measure your ability to perform specific work-related activities like standing, walking, lifting, or hand dexterity. A job-specific FCE may be able to simulate your real job duties to show how your functioning compares to those requirements.
- Pulmonary Function Tests or Cardiac Stress Tests: For conditions affecting respiratory or cardiovascular function, these tests can quantify limitations in stamina and endurance.
- Neuropsychological Evaluations: These formal tests assess memory, concentration, processing speed, and executive function. They provide measurable data rather than relying solely on self-reports.
- Standardized Psychiatric Assessments: Validated questionnaires and clinician-administered tools can objectively measure mental health symptoms and their severity.
- Clinical Observations: Physical exam findings in appointments or the observations of the providers who evaluated you are may be objective evidence already contained in your medical records. Doctors who have treated you over time can also provide thorough narrative opinions explaining how your condition limits your functional abilities, referencing both subjective symptoms and objective findings.
—
Bridging the Gap
If your LTD claim was denied because of “lack of objective evidence,” it does not mean your symptoms are not real. Rather, it means that the insurer, and possibly a reviewing court, needs more measurable proof of how your condition prevents you from working.
When you are preparing your initial claim or appeal, working with your providers to obtain evaluations like those referenced above can make the difference between a denial and an approval. Furthermore, during an appeal, it often becomes necessary to provide a more detailed explanation that explicitly connects the dots for the insurer between your documented limitations and your inability to perform your specific job duties. Insurers want to see a clear, logical link demonstrating how each functional limitation directly impacts your ability to meet the essential demands of your work. For example, if you work in a cognitively demanding and high-pressure role that requires prolonged focus and rapid processing of information and your neuropsychological testing shows significant deficits in working memory and processing speed, you’ll need to explain how those specific impairments prevent you from performing necessary job duties such as reviewing complex information, meeting deadlines, or reliably making analytical decisions under time pressure. Taking the time to make this connection clear can be a critical factor in persuading the insurer to approve benefits on appeal.
If your claim has been denied due to lack of objective medical evidence (or you want to prevent this denial from happening in the first place), an experienced LTD attorney can help you determine the best form of objective medical evidence for your case and how to best present your claim to the insurer. Contact our team today if you would like to discuss your case.