A typical scenario for a day in my office would be for an insured to provide me with copies of his/her medical records specifically to locate medical Restrictions and Limitations. Although I have been assured by the insured that “my doctor writes very good restrictions and limitations” something really strange happens. After going over the records several times, there is not an R&L to be found.
Before I begin I would like to point out something you probably don’t know. Physicians are used to filling out paperwork for Social Security applications where the standard of proof is “FUNCTIONAL CAPACITY”. The definition of “functional capacity is documenting the applicant’s physical or mental incapacity to perform any job in the national economy for which they have education and experience to perform.
Private disability insurance requires documentation of medical (or mental) RESTRICTIONS AND LIMITATIONS precluding the individual from working in their own, or any other occupation. FUNCTIONAL CAPACITY AND RESTRICTIONS AND LIMITATIONS require completely different “proofs of claim statements” that physicians often don’t know, even when they claim to have prior experience documenting private disability claims. Unfortunately, physicians “think” that SSDI and private disability are supported by the same terms and statements. THIS IS NOT TRUE.
Private disability is an entirely different “support methodology” than Social Security and is supported with medical/mental Restrictions and Limitations that preclude you from working. Therefore, the first correct support for private disability is to make sure R&Ls are always work related.
The definition of a “Restriction” are job tasks you MAY NEVER DO, such as when a physician reports, “this patient is permanently restricted from repetitive keyboarding, and/or attempting any sustainable work in which he/she is likely to be unsuccessful.”
The definition of a “Limitation” is “work tasks you may DO but only to a limited extent. Example documentation, “this person is limited to walking >than 10-15 minutes, sitting and standing limited to accommodated alternative sitting, standing, walking….” I often see “limitations” written in the “restrictions” boxes of update forms, and that would be incorrect.
“Functional Capacity” written for Social Security (SSDI) might say, “Patient is capable of only Sedentary Work Capacity on a part-time basis.” You can easily see the difference. If private disability insurance doesn’t get what it needs, either you and your doctor will be harassed until it does, or, your claim will eventually be denied.
Insurance companies request what is wants. Neither an attorney, nor doctor will be able to “talk” or “document” your claim into payment status when it’s not getting the proof it needs. I can’t tell you how many insureds attempt to convince me that their patient notes have “excellent R&Ls”, when what it really documents is functional capacity for SSDI.
Therefore, the quickest path to a claim denial is NOT to provide clear, specific, and accurate medical/mental restrictions and limitations precluding work in your own or any other occupation. Then, too, treating physicians aren’t stupid. I’ve had several physicians refuse to provide credible “real” R&Ls without Functional Capacity Evaluations. This is a disastrous problem sometimes for insureds who continue to allege their records contain R&Ls when they really don’t.
Please make sure you and your physician are documenting R&Ls and not FUNCTIONAL CAPACITY. Insisting your R&Ls are well documented when they are NOT will get you a whole lot of harassment, but unfortunately your benefits won’t get paid.
If you are considering retaining assistance and would like to explore coming on board as a client, please visit: http://www.disabilityclaimssolutions.com or contact me by email: lindanee.dcs@gmail.com.
I’d love to hear from you.
