Occupational Disability Coverage and Functional Capacity Evaluations
Ensuring the Fair Adjudication of Your Long-Term Disability Claims
Whether you’re eligible for individual or group long-term disability benefits depends on whether a disabling illness or injury prevents you from performing the material and substantial duties of your occupation. Many individual and group long-term disability insurers wrongfully delay, deny, or terminate long-term disability payments, claiming you don’t have a qualifying injury or illness. Your individual or group long-term disability insurer may claim the injury or illness was preexisting, self-inflicted, not covered, or is normal for your age.
The top-rated long-term individual disability lawyers and nationally prominent group ERISA attorneys at DarrasLaw deal with wrongful disability denials daily. However, you may still face a wrongful denial of individual or group long-term disability benefits even if you present objective medical evidence of a qualifying injury or illness. Proving you have a disabling injury or illness is only half the battle. The second half is proving that your injury or illness prevents you from reliably performing the important duties of your occupation.
At DarrasLaw, our award-winning long-term individual disability attorneys and nationally preeminent group ERISA lawyers protect claimants at every stage of the long-term disability claim process. Contact DarrasLaw to schedule your free disability policy analysis and free claim consultation today. From wrongful denials to complex ERISA litigation and administrative appeals, our founding partner, Frank N. Darras, and his firms have recovered nearly $1 billion in wrongfully delayed, denied, and terminated insurance benefits. Call us today at 800-898-7299 or contact us online.
Types of Individual and Group Long-Term Disability Occupational Coverage
Private, for-profit insurance companies provide a majority of long-term individual and group disability insurance policies. Each individual and group long-term disability policy will have different terms and limitations. Disability insurers typically define a disability as an injury or illness that prevents you from performing the important duties of your occupation with reasonable continuity and in the usual and customary way. The various types of policies will define your occupation differently.
The three main types of occupational coverage include:
- True own occupation coverage – Your duties are defined exactly as you usually and customarily performed them in the regular course of your day at the onset of your disability.
- Modified own occupation coverage – You can’t perform the material and substantial duties for 10 years, or until age 55, whichever is longer.
- Any occupation coverage – You can’t perform any occupation for which you are trained, educated, or suited, taking into consideration your station in life. The Social Security Administration uses a similar standard in determining an individual’s eligibility for SSDI benefits except without reference to what you earned.
Understanding your policy’s occupational definitions is essential to claiming individual or group long-term disability benefits. For example, if you’re a neurosurgeon who can’t stand for more than an hour, you may qualify for individual or group long-term disability benefits under “true own occupation coverage” but may be not under “any occupation coverage.” Under the “any occupation” definition your insurance company would argue your undergraduate and medical school training would qualify you to teach science or biology or do medical research even though you couldn’t operate. The premier long-term individual disability lawyers and stellar group ERISA attorneys at DarrasLaw can conduct a free disability policy analysis and free claim consultation to identify your type of coverage.
Functional Capacity Evaluations and Long-Term Disability Coverage
You must show how a disabling illness or injury prevents you from performing the material and substantial duties of your occupation to claim individual or group long-term disability benefits. Sometimes this is obvious: For example, an insurance company would almost certainly agree that a bus driver with a broken right leg could not safely drive the general public.
When your treating doctor and individual or group long-term disability insurance company disagree about your ability to perform the important duties of your occupation, you may be asked to undergo a Functional Capacity Evaluation (FCE). According to the American Occupational Therapy Association, an FCE “evaluates an individual’s capacity to perform work activities related to his or her participation in employment.” It is used to determine whether:
- You can safely perform your occupation’s duties
- You need modified or reduced demand work assignments
- You’re physically disabled
- You can meet your occupation’s important demands physically
- You can participate in other physical activities
A professional evaluator, such as an occupational therapist, will look at your medical records, conduct an interview, and request that you perform specific tasks, such as:
- Carrying
- Pushing and pulling
- Lifting
- Bending
- Sitting
- Standing
- Walking
- Balancing
- Reaching
- Object manipulation
- Kneeling
The evaluator then looks at your type of policy and your occupation to determine whether you’re able to perform the important duties of your occupation.
FCEs are limited, however, because they only evaluate physical disabilities. You may not benefit from an FCE evaluation if you suffer from depression, substance abuse, or other mental health and self-reported conditions.
Are Functional Capacity Evaluations Reliable?
You are responsible for reporting your level of pain while performing the testing during the FCE. A claimant’s failure to report pain is one of the most common issues we see with FCEs. For example, you may sit when the evaluator says to. If you don’t explain that you’re suffering from extreme back pain, the final report will say, “Can sit without pain.”
There is no one licensing body that performs FCEs. Your physical therapist, occupational therapist, or treating doctor may all claim to perform them. This calls an FCE’s reliability into question. While certain standards exist for FCEs, your individual or group long-term disability benefits may depend on the qualifications and subjective observations of their FCE evaluator.
For example, an evaluator familiar with neurological disabilities may make note of speech impediments. Often evaluators produce an inaccurate or incomplete FCE. There are also different types of FCEs. There are “occupation-specific” FCEs and “general” FCEs.
A general FCE may evaluate your overall health in the context of personal injury litigation or against the activities of daily living. Occupation-specific FCEs, on the other hand, assess how a claimed disability interferes with your ability to perform the important duties of your occupation. For example, you probably won’t have to type during a general FCE, but the person conducting it will likely evaluate your ability to move your wrists, fingers, and neck for specific periods of time. On the other hand, if typing is an important part of your occupation, an occupation-specific FCE may evaluate your ability to do find motor movement frequently.
Functional Capacity Evaluation FAQs
When it comes time for a functional capacity evaluation (FCE) as part of objectifying your disability claim, you might have several questions. The following are only some brief answers to some common questions we often hear. If you would like to discuss questions regarding your specific situation, please contact our disability attorneys directly.
Is an FCE right for my claim?
FCEs may not be effective at measuring every kind of disability. These tests are most successful at evaluating physical conditions that result in abnormal movement abilities, including difficulty sitting, standing, walking, lifting, carrying, reaching, muscle weakness, pain, poor balance or coordination, and other movement-related impairments. It is not as effective for cognitive impairments, vision loss, hearing loss, and similar conditions.
How long does the FCE take?
This varies depending on who is conducting your evaluation. Some happen for a half day, while others last for one or two days. If you have a one-day evaluation, prepare to be there the entire day unless someone tells you otherwise. In some cases, it is preferable to have a two-day evaluation, as this can measure your disabilities over a more sustained time.
How should you prepare for your FCE?
Make sure that you dress in clothing that is comfortable and does not cause any limitations. Bring your prescription medications and assistive devices that you use to help manage the symptoms of your disability.
Your disability attorney should already be in touch with the evaluator and provide your medical records to them for their review. Your attorney should also inform them of your background, occupation, date of disability, diagnosis, and treatment plan and medications.
What will the evaluator do?
The evaluator will engage in different activities to test your ability levels. They will ask you questions directly to get the best idea of your diagnosis and condition.
You may undergo tests to evaluate your:
- Ability to sit or stand
- Ability to walk
- Ability to carry or lift items of various weights
- Fine and gross motor skills
- Physical strength
- Postural intolerances
- Range of motion
- Fatigue levels and blood pressure, along with heartbeat monitoring
If you have two days of testing, you might have to undergo the same tests twice to measure how your abilities might differ from day to day.
The evaluator will observe you during the testing to make sure that you put forth maximum effort for each test. If you do not display maximum effort, it can affect the reliability of the evaluation results.
What happens if I need to stop the test?
Sometimes, symptoms might worsen during one or more tests, and you should inform the evaluator if this happens. They might have you omit certain tests and adjust the further testing based on your escalating symptoms. You should never perform tests as part of the FCE that jeopardize your safety or physical condition.
It is very common for people to become fatigued during this evaluation, as you should be exerting maximum effort for all the tasks. Tell the evaluator if you are getting overly tired, and that you might need a break. They will also note which activities caused your fatigue, which can help with the overall evaluation.
Don’t Delay. Schedule your Free Long-Term Disability Policy Analysis and Free Claim Consultation With DarrasLaw Today
A Functional Capacity Evaluation can either hurt or help long-term disability claimants. At DarrasLaw, we’ll review the terms and conditions of your individual or group long-term disability policy to ensure you receive the right type of Functional Capacity Evaluation. If you have “any occupation” coverage, you may want a general FCE. If you have “true own occupation coverage,” you may need an occupation-specific FCE.
DarrasLaw’s award-winning long-term disability attorneys and top-rated group ERISA lawyers understand disabling injuries and illnesses. We know what an FCE looks at and can suggest protections for you during the insurance company examination.
Call DarrasLaw today at 800-898-7299 or contact us online to schedule your completely free disability policy analysis and free claim