Functional Capacity Tutorial by Linda Nee

Although private disability policies continue to require insureds to be “unable to perform material and substantial duties” in order to qualify for benefits, insurers continue to concoct misrepresentations of what physical/mental functional capacity is, and how it should be credibly determined.

If one examines a typical functional capacity evaluation questionnaire, it becomes obvious that Unum’s (and other insurers’) Attending Physician Statements are mirror images of recommended opinions for determining insureds’ physical capacity. APS forms basically ask treating physicians for their “opinions” as to functional capacity since in truth, they haven’t evaluated it. Some physicians refuse to comment about functional capacity and rightly so.

First, my definition of physical or mental functional capacity is, “the degree to which individuals are able to physically or mentally perform those activities required to sustain ¬†self-care, in addition to, and including, reasonable job tasks sufficient to acquire financial independence and stability.” Although some might not entirely agree with my definition, in my opinion, it fits perfectly with the concept of disability and impairment.

Insurers, however, give themselves a wide berth when it comes to devising claim management strategies that “opine” what functional capacity is, and whether insureds have it sufficiently enough to allege they can work. Most private disability medical resource peer reviewers include statements about “physical functional work capacity” without ever having actually tested, or evaluated it. In the end, most medical reviews, whether out-sourced, or performed in-house, represents “opinions” of functional work capacity rather than precise evaluations of it.

The most egregious strategies I’ve encountered by a private insurer is Unum’s rather sophisticated methodology of equating METS to levels of functional capacity. For example, demonstration of 5 METS on a treadmill stress test equals at least “sedentary capacity for work” and so on. At least Unum attempts to allege work capacity using, in its opinion, in-house objective and statistical categorizing, the result of which is still opinionated and subjective.

Other attempts to rationalize functional capacity in order to deny claims becomes quite silly really. For example, The Hartford’s most recent attempt to allege that writing a letter in defense of a claim demonstrates work capacity, or Unum’s claim that using it’s website portal does the same seems incredibly deceptive on the part of insurers to allege work capacity where none exists. In addition, a three-day surveillance is no indication of work capacity either.

Although discussing the credibility of Functional Capacities Evaluations is another article entirely, it can reasonably be said that without a formal “physical or mental functional capacity evaluation”, the status of work capacity cannot be accurately measured. When one considers that many disability claims are worth millions in financial reserve, the concept of “guessing”, or “providing self-conflicted opinions” as to insureds’ work capacity should not be acceptable to anyone, or any industry for that matter.

It seems obvious to me that the issue of “work capacity” from the insurers’ point of view is automatically pointed, or directed to alleging work capacity so that more claims can be denied.

All of the information I’ve reviewed, including the criteria of SSA, suggests that functional capacity should be determined in combination with a complete medical history of physical activity and personal conditioning in additional to physical work tasks customary and historically sustained by the individual.

In the end, insurers’ opinions and misrepresentations about physical functional capacity are deliberately intended to allege work capacity where none exists. Without a credible evaluation including validity testing, work capacity really can’t be accurately determined, particularly by a third-party paper reviewer.

It’s important to keep in mind that despite insurer attempts to allege work capacity, the “opinions” rendered are not accurate assessments of demonstrated work capacity.

The more you think about this, the more you realize insurers are experts in writing their own “Aesop’s Fables.” Most of the strategies insurers use to evaluate claims are no more than opinionated misrepresentations that give the illusion of credibility.