Rheumatoid Arthritis and Long-Term Disability Benefits
Rheumatoid arthritis (RA) can become an unexpected and disruptive condition. Persistent joint pain, debilitating fatigue, and unpredictable flares can make working impossible. In these situations, long-term disability (LTD) benefits may be necessary.
Despite the serious impact RA can have, LTD claims for rheumatoid arthritis can still receive denials. Often, insurance companies will cite insufficient evidence or suggest that the claimant is still capable of performing sedentary work. In short, obtaining LTD benefits can be challenging.
In this article, CCK Law will discuss:
- How rheumatoid arthritis affects professional work
- When RA qualifies for long-term disability benefits
- What evidence can strengthen an LTD claim for RA
- How to file an appeal with your insurer
- And more
A Brief Overview of Rheumatoid Arthritis
Rheumatoid arthritis is an autoimmune condition that affects a person’s joints. It is a chronic condition and causes pain, swelling, and inflammation. While it primarily affects the joints, it can damage other parts of a person’s body, too, including the skin, lungs, heart and blood vessels, and eyes.
RA is progressive, meaning it tends to worsen over time. The symptoms — like joint pain and swelling — can get worse and spread to other joints in the body. Moreover, symptoms can come and go over time. When the condition is active, it is called a “flare,” and when it is less active or is absent, this period is called “remission.”
Joints affected by rheumatoid arthritis can become bent and shift out of place. Likewise, the effect this condition has on a person’s joints can make performing daily tasks — both at home and at work — difficult to perform.
How RA Interferes with Professional Work
Suffering from RA can be challenging because it can affect several facets of life. It can affect fine motor skills, such as typing, writing, and performing procedures. It can also affect endurance and mobility, such as sitting, standing, or walking for long periods. Likewise, executive functioning can be diminished by symptoms such as fatigue and pain.
Rheumatoid arthritis flares can be unpredictable, which makes it difficult to maintain consistency at work. For example, some individuals may miss work because they cannot physically get there on time.
Treatment is necessary to manage this condition, but there is no cure. Certain medications can cause brain fog, which can further inhibit a person’s ability to perform the occupational duties of their jobs.
When Rheumatoid Arthritis Qualifies for Long-Term Disability Benefits
Long-term disability benefits can help cover a percentage of a person’s income when they cannot work for an extended period. Rheumatoid arthritis can qualify for such benefits, but individuals must prove that it prevents them from working under the terms of their insurance policy.
All LTD claimants, regardless of their conditions, must meet their policy’s specific “definition of disability.” Every policy contains such a definition. A person may have to meet either an “own occupation” or an “any occupation” definition, which can be defined as follows:
- Own occupation: This definition asks whether RA prevents you from performing the duties of your own occupation as it is defined in the national economy. In other words, if you’re a surgeon, can you still perform the material duties of a surgeon?
- Any occupation: This definition asks whether RA prevents you from performing the duties of not just your own job but any job whatsoever. A surgeon may no longer be able to perform their duties, but could still perform the duties of a different, sedentary job and therefore not be considered disabled under this definition.
It is important to note that a person does not need to be bedridden to qualify for LTD benefits. If a person can prove that they meet their insurer’s definition of disability, then they can receive benefits.
Evidence LTD Claimants Should Gather
If a person is suffering from rheumatoid arthritis and cannot work, then they can file for LTD benefits. There are three stages of the claim and appeal process:
When filing the initial claim, it is crucial for the claimant to gather evidence that proves their condition disables them from working. For rheumatoid arthritis claims, evidence can include:
- Comprehensive medical records, especially from a rheumatologist
- Imaging and lab tests
- Functional capacity evaluations (FCEs)
- Physician statements detailing the claimant’s limitations
- Witness statements from friends, family, and co-workers
- Vocational evaluations that show how RA prevents them from performing the specific duties of their job
- Symptom journals
Insurance companies prefer objective evidence when reviewing LTD claims. Yet many RA symptoms, such as pain and fatigue, are subjective. Therefore, it is important to include as much objective evidence (e.g., imaging results or FCEs) as possible.
This evidence, along with the insurance company’s claim forms, should be submitted during the initial claim stage. Once received, the insurance company will review the claim and then issue a decision. Under ERISA, insurance companies have 45 days to issue a decision. However, they may request a 30-day extension if they believe more time is needed.
Why Insurance Companies Deny RA Disability Claims
Insurance companies frequently deny long-term disability claims. Insurance companies are often focused on limiting payouts, which can lead them to closely scrutinize or deny valid claims. However, all claimants who receive a denial of their initial claim have the right to file an administrative appeal.
Nonetheless, reasons insurance companies deny RA claims often include:
- A lack of objective evidence, such as medical records
- Surveillance shows the claimant engaging in an activity they claimed they could not do
- Arguing that the claimant can still work a sedentary job, or that their symptoms are not severe enough, or that treatment is working even if it isn’t
- Independent medical exams discredit a claim, though these exams, often arranged by insurers, may not fully reflect the claimant’s condition.
Regardless of the reason an insurance company denies a rheumatoid arthritis claim, it will send the claimant a denial letter in the mail that outlines all the reasons for the denial. It is important for LTD claimants to thoroughly read this letter before filing their appeal.
Filing and Appealing a Denied LTD Claim for Rheumatoid Arthritis
Fortunately, long-term disability claimants have the right to file an administrative appeal if they receive a denial of their initial claim. If ERISA governs their claim, then they have 180 days to file this appeal. This filing deadline is important; missing a deadline can lead to a denial of the appeal.
Nonetheless, the administrative appeal stage is often the last time a claimant can get evidence on the record. Insurance companies expect appeals to contain all relevant information needed to evaluate the claim. Once the appeal window closes — except in rare circumstances — no new evidence may be submitted, even if it proceeds to court (under ERISA).
Thus, reviewing the denial letter can help claimants choose the right supplemental evidence to add to their claim. For example, if the denial letter cites “insufficient medical evidence” of the disabling condition, then the claimant can submit medical evaluations of their rheumatoid arthritis.
If the appeal is denied, claimants may have the option to file a lawsuit in federal court. However, no new evidence may be added at that stage, which is why the administrative appeal is so important.
How CCK Law Helps with Long-Term Disability Claims and Appeals
The long-term disability claim process can be challenging for those suffering from rheumatoid arthritis. Getting long-term disability benefits can be overwhelming, especially if the insurance company denies the initial claim. Yet this is not a process that individuals must do on their own.
CCK Law has been helping LTD claimants for over 25 years. Arthritis, including RA, is one of the most common conditions for which individuals seek LTD benefits. We understand how debilitating this condition can be and how challenging the claim and appeal process can become.
We can help long-term disability claimants with RA at any point in the claim and appeal process. Some of the ways we help our clients include:
- Identifying insurer errors
- Gathering and submitting all evidence to the insurance company
- Acting as a point of contact with the insurance company and treating doctors
- Tracking all filing deadlines
- Ensuring all claims are compliant with ERISA
- Litigating in court when necessary
- And more
Need Help with Your Long-Term Disability Claim or Appeal?
CCK Law has been helping LTD claimants since 1999 get the disability benefits they need and may be able to help you, too. Our team knows what insurance companies look for in successful claims and will work to strengthen your claim and increase your chances of success.
For a free case evaluation, call our office today at (800) 544-9144. A member of our team can evaluate your case and determine if we can assist.
