Functional Capacity vs. Restrictions And Limitations

Did you know?One of the most important mistakes insureds, treating physicians, and attorneys make is confusing Physical or Mental Functional Capacity with Medical Restrictions and Limitations. I can understand how this might happen since we have three different entities in the United States that pay benefits for disability: Social Security, Workers’ Compensation, and Private Disability. Each one of the three sources of disability benefits have different standards for payment and people get confused

Social Security

Although Social Security has a 15 step review process, claims often hinge on “functional capacity” particularly if the reported total disability does NOT exactly meet an SSDI listing. The burden of proof then falls to “functional capacity”, or “How does the impairment affect the applicant’s ability to function in their day-to-day lives.” Therefore, SSDI paperwork contains many pages of questions related to “functional capacity.”

To clarify, functional capacity is defined as the individual’s ability to sit, stand, walk, bend, stoop, kneel, lift, carry, or for mental patients, the actual mental capacity for self-care. This is why a “Functional Capacity Evaluation” measures all of these things. Technically, functional capacity per se has very little to do with private disability particularly since SSA is evaluating “total disability” from any job, not just incapacity to do one’s own occupation.

Additionally, SSA makes inquires as to how an individual’s functional capacity affects the ability of an individual to function particularly when impairments do not exactly meet a particular listing. Then, the burden of evaluation falls almost exclusively to a “functional capacity standard”.

Workers’ Compensation

Worker’s compensation relies on percentages of “whole body disability” because WC standards are written that way to determine compensation. Physicians who deal with WC primarily often produce records giving percentages of whole body disability, not statements about functional capacity or medical restrictions and limitations although these issues may be discussed during negotiations.

Actual benefits received from WC are variable and depend on negotiation surrounding evaluations of bodily disability. There is no contract involved with WC, and percentages of impairment are needed to evaluate compensated settlements.

Percentages of whole body disability aren’t helpful to reviewers of private disability since the standards are not indications as to how any medical impairment precludes employees from working. Workers’ Compensation requires an entirely different standard of medical review resulting in percentages of total body disability – a measure that is not relevent to private disability. When I see these types of references in medical records I know immediately that the treating physician is well familiar with Workers’ Compensation.

Private Disability

Private disability is entirely different from SSA and Workers’ Compensation since it is  possible for someone to have difficulty bending, stooping, sitting, standing etc., and still be able to work; “sedentary” work capacity is pretty easy to allege as long as someone is still breathing. (Sorry for the sarcasm!) The definitions of disability for private insurance are always work related – an issue that is missed by insureds, their treating physicians and even attorneys. 

Again, to clarify, a medical restriction is defined as: “Work activities that patients may NEVER do”, and a medical limitation is defined as: “Work activities that patients MAY DO, but only to a limited extent. The missed concept here is – Medical providers must always CONNECT THE DOTS between impairment assessment and the patient’s inability to work. This is why private insurance is more interested in medical R&Ls than functional capacity, or whole body impairment percentages.

However, because private disability is determined by “risk management” (paying the least number of claims possible), the “gotcha” kicks in. Nearly all update forms from insurers include a section for “Functional Capacity” and “Restrictions and Limitations”, or insurers leave out R&Ls entirely.

Insurers who deliberately “leave out” sections for medical R&Ls will then harass physicians indefinitely trying to obtain them. It has gotten to the point now that some physicians line through the functional capacity sections and refuse to fill it out stating functional capacity should be “evaluated” not assigned. And, they are not wrong.

Let me give you an example of the difference between “functional capacity” and R&Ls. Functional capacity sections on forms generally ask physicians to indicate lifting, sitting, standing, bending, stooping, reaching overhead, carrying etc. In fact, Unum’s Physician Update Form asks these questions under a heading of “Functional Capacity.” The doctor checks the appropriate boxes only without comment.

Please note that the information for functional capacity DOES NOT MEET the burden of proof for a definition of disability that states “……unable to perform the material and substantial duties of own/or any other occupation.” There has been no “connect the dots” between impairment and work ability.

However, medical restrictions and limitations do the trick:

“This patient is permanently restricted from his own occupation as an Anesthesiologist to include requirements of on-call weekends, and variable long accommodated work hours. He is also medically restricted from handling instruments and having accountability in the surgical arena that places himself and his patients at significant risk. These restrictions include no prolonged standing, bending over patients, fine bilateral finger manipulation including intubation, and other duties associated with anesthesiology.

In addition, this patient continues to experience limitations involving physical endurance, levels of fatigue, and drowsiness due to medical side-effects. These medical restrictions and limitations are likely to be permanent until further notice.”

I think you’re getting the idea of the difference between functional capacity and medical R&Ls. In fact, it’s my belief that treating physicians cannot “connect the impairment and work dots” without being provided with a copy of the patient’s job description and having a conversation about what “material and substantial duties” patients are having trouble doing due to the claimed disability. A medical diagnoses DOES NOT equal disability, and treating physicians need to spell it out.

Physicians are not mind readers, and in order to provide the correct restrictions, physicians need to document not only diagnoses, but how the impairment impacts the patient’s ability to work, first in their own occupations, and then inability to work at all.

Although some insureds emphatically insist that their physicians are doing a good job with documentation, when I review the records I can’t find a medical restrictions or limitations statement among them. This is not something physicians do very well unless they  have been in the private disability loop a long time.

In any event, I decided to write this article as a caution to insureds that functional capacity statements, or percentage whole body impairment ratings are NOT sufficient proof for private disability purposes.

Most insureds need to pay more attention to the forms completed by their  physicians Disability  insurance is not the same today as it was even two years ago.

The process is what it is, and requires what it needs.