Physical and mental “functional capacity” is quickly becoming the major determination factor to make benefit decisions regarding claims. While treating physicians are more reluctant to certify to “functional capacity”, insurers are putting their stakes in the ground to determine physical activity levels. If treating physicians fail to document, I can assure you insurers will be more than happy to do it themselves.
My definition of functional capacity for disability claims is: “The reasonable determination and identification of physical or mental levels of activity needed in order to be able to perform occupational or job tasks on a full-time basis.” This definition of functional capacity is consistent with definitions of disability that connect an individual’s medical restrictions and limitations with an inability to work.
Insurers have narrowed functional capacity levels down to a science by identifying the number of METS of each described activity reported by insureds themselves. For example, carrying laundry is 5 METS, gardening is 6 METS, etc. Five METS is equivalent to “sedentary work capacity”, therefore, technically, anyone who carries laundry can work a sedentary job. 1 MET is a metabolic unit equal to someone sitting in a chair. 5 METS is then 5 times the amount of energy required to perform any activity as compared to sitting calmly in a chair. Ten METS would require 10 times the energy, or equate to “Light Functional Capacity.”
Why do you think insurers are always so anxious to ask you about your physical activities? If they can objectively calculate the number of METS as evidenced by your reported activities, your functional capacity for work can easily be determined. Unfortunately, insurers can use their “objective data calculations” to support denials, even on appeal.
For disability claims, Functional Capacity is always determined as a person’s ability to perform work.One of the biggest mistakes insureds make in managing claims is omitting connecting the dots between medical restrictions and limitations and occupation. Most insureds are not knowledgeable enough of how to do this, and it can become a problem, particularly if treating physicians are unaware as well.
The best thing to do is to make sure your treating physicians document your medical restrictions and limitations specifically, mentioning physical functional capacity in relation to occupation. Insureds should not allow any insurance company to determine independently what their functional capacity is.
Disability Claims Solutions, Inc. provides disability claims consulting and assistance to insureds with both ERISA and IDI Plans and policies.
If you would like to know more about how to become a client, please feel free to visit my website at: http://www.disabilityclaimssolutions.com or call 207-793-4593
