If I were to ask my readers what they thought the single most factor is to a successful claim review, most would probably respond, “Restrictions and Limitations”. However, that’s not the case. FUNCTIONAL CAPACITY for work is THE most important factor to have on your side to assure the best successful outcome for the duration of your claim.
There is a great deal of confusion among insureds and claimants as to what “functional capacity” really is. If you look up the definition on the Internet you may be given the impression that overall ability to perform activity is most important. However, private disability has its own unique definition, which I defined myself. It is, “Functional Capacity is an individual’s medical ability to physically and/ or mentally perform the material and substantial duties of the job or occupation insured by a policy or Employer’s Plan.”
Social Security disability also follows the same criteria to determine SSDI approvals. Functional Capacity is so important to these two products that no claim can be paid without determining WHAT the insured’s functional capacity is.
Functional Capacity as it pertains to private disability is a bit difficult to explain since a person, somewhere must make a decision as to whether R&Ls or observed surveillance proves Functional Capacity for work. Imagine a large wooden barrel where patient notes and other medical information is thrown in, perhaps even surveillance reports.
A claims manager must look at the evidence and decide whether the insured demonstrates the ability to do their job. Seems to me there is a great deal of advantage there since not all claims are reviewed anymore by vocational rehabilitation specialists, or CRCs who are qualified to make those decisions. Mistakes and denial decisions are often made by claims handlers who have no idea how to evaluate Functional Capacity.
There are so many additional factors associated with Functional Capacity that I couldn’t possibly cover them all here. Still, it’s clear that insurance paper-reviewing physicians may also not have good training to determine functional capacity, forcing them to document the same old jargon such as, “There are no restrictions and limitations that preclude working.”This process can be very, very wrong.
As an example, consider a Rite Aid store manager who, in addition to his managing duties, also carries boxes and stocks shelves along with various other physical duties. He develops radiculopathy, files disability because he can no longer lift, carry and continuously walk. Rite Aid’s Plan defines disability as “the inability to do one’s own occupation.” Unum, for example investigates and finds the “occupation” of a Rite Aid Store Manager is listed as sedentary even when the manager is expected to engage in physical activity on the job.
It’s important to realize that an occupation is NOT the same as a job. In fact, ERISA Employer Plans DO NOT insure an individual’s job, only inability to perform one’s occupation. Therefore, the manager’s claim will be denied when a medical resource documents the manager is still able to perform his OCCUPATION even when he can’t do his own JOB. A real bummer, huh? Another way of saying this is that Unum determined the claimant had the functional capacity to do a sedentary occupation, even when he could no longer perform the FUNCTIONAL CAPACITY of his own job.
Some readers may have to think about this for awhile before really understanding the significance of what this could mean. Insurance companies don’t always get away with this, but it is legal since the ERISA Plan language specifically says “occupation”, not job. IDI policies define and insured one’s JOB, so no worries there although Functional Capacity, when in question, is determined by Independent Medical Examinations, which ARE defined in the policy itself.
Functional Capacity has become such an issue that many treating physicians refuse to complete the Functional Capacity boxes on most update forms without Functional Capacity Evaluations. Nevertheless, the ability to sit, stand, walk, carry, kneel etc. is an indication of physical functional capacity objectified by an FCE.
I can imagine that some readers might ask, “OK, what’s the difference between restrictions and limitations and functional capacity. Restrictions are work activities the insured may NEVER DO, and limitations are work activities the insured may do, but only to a limited extent. R&Ls determine functional capacity specifically for the occupation covered by the Plan.
Insurance companies don’t care if you walk around the Mall for five hours with your grandchildren, what they care about is that you are demonstrating the functional capacity to continuously walk. If this is a material duty of your job, then you are demonstrating functional physical capacity for work.
Making decisions regarding disability claims involves more than just submitting paperwork from physicians supporting claims. As I indicated above, the information I’ve written about just slightly addresses all that is involved with determining Functional Capacity. I have written other articles on Functional Capacity, if you are interested you might try a Search from the homepage to find them.
Functional Capacity is a very complex subject, which is an indication of how important it is to making claim decisions.
