Winning Isn't Easy: Long Term Disability ERISA Claims

Episode 20: What You Need To Know About Providing Your Disability Insurance Carrier With Adequate Proof of Loss

January 11, 2021 Nancy L. Cavey Season 1 Episode 20
Winning Isn't Easy: Long Term Disability ERISA Claims
Episode 20: What You Need To Know About Providing Your Disability Insurance Carrier With Adequate Proof of Loss
Show Notes Transcript

In this week's episode - Nationwide ERISA Long Term Disability Attorney Nancy Cavey talks about  "What You Need To Know About Providing Your Disability Insurance Carrier With Adequate Proof of Loss" and much more!

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Nancy L. Cavey:

Hey, I'm Nancy Cavey national ERISA and individual disability attorney. Welcome go winning. Isn't easy. Before we get started, I'm going to give you a legal disclaimer. This podcast is not legal advice. The Florida bar association says, I've got to say this. So I've said, but nothing prevents me from giving you an easy to understand overview of the disability insurance world, the games that carriers play and what you need to know to get the disability benefits you deserve. Ready today. I'm going to talk about what you need to know about what the disability carrier is looking for in your proof of loss. What you need to know about the proof of claim forms you'll be sent by the disability insurance carrier and the role of your doctor in your application for benefits. Let's take a break. Once we get started, I look forward to talking to you about these great topics.

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Nancy L. Cavey:

Ready to get started. Let's talk about what you need to know about what the disability carrier is looking for in the proof of loss. Now, the first thing you have to do when you've decided that you're going to apply for your disability insurance benefits is to put the carrier on notice of the claim and you can call them up or prayerfully , or you should , uh , send them an email or , um, just send some form of a communication than asking for , uh, the proof of loss forms. So guys put them on notice. And then when you do that, guess what happens? You're going to get lots of forms, forms, and more forms. So let's talk about the claim form. There is no uniform claim for language and disability and trust policies, but let me give you an idea of what an example might look like. It might say, we'll send you a claim form within 10 working days of receiving the notice of claim. If the claim form isn't received within 15 days after the notice of claim is sent to us, you, the owner should write us a letter about the claim, describing the cause and extent of your loss in detail. While the law policy will suggest here that you should write a letter. I suggest that you call the agent or contact your HR department to ask for the proper claim form. I don't like the idea of writing a letter describing the cause and extent of your loss in detail, because you don't know what are they're going to do with that information that you provide. You might provide too much information, not enough information. So I really think that you should be contacting the agent or your HR department to ask for the proper claim form. So you're providing them with just the information they need and no more. So what's the next form? Well, I said more forms, more forms. So first is notice the next is going to be an application form. Now the application form , uh , again, is a form that is carrier specific. Uh, and it may ask you information about your basic demographics, your address, your date of birth , um, your occupation when you became disabled, what the disabling condition is. Um, I like to keep these short sweet and to the point , um, I don't like to go into any extensive detail unless I'm doing the application because I know what I'm doing. And unfortunately you don't, and it's pretty easy to make mistakes in the application by not answering the question correctly or not giving them the right information. Now, another important form is the occupation form to me, this is going to make or break your application. Well , why do I say that? Cause that's pretty dramatic. The , uh, disability policies will normally pay you two years of benefits for an inability to do your own occupation. And then the definition of disability will change to any occupation. You should get out that disability policy and read what the definition of occupation is that occupation might be, as it's performed in a national economy, might be performed according to a book called the dictionary of occupational titles, or it might be , uh , as actually been performed for your employer or in your local economy. So before you fill out that form, you need to understand what the definition of occupation is. I tell my clients to work backwards, but what do I mean by that? When you think about the physical problems or the psychiatric problems or the behavioral problems that you have that have led you to file a claim for disability benefits, I want you to think about the occupational duties that you have that you having trouble with, or you can't do at all, because we want to make sure that the occupational duties cover the duties that in fact you're having difficulty performing. So we don't really skip anything because ultimately we're going to connect this with your physician. Now your employer might have a description of your occupational duties and you want to get that , uh, before you fill out the form. I think that's important because I asked my clients to get that occupational description form, job description form from the employer and get out a piece of paper and write down what is not included in the employers , um, occupational description or job description and what , um, what is included that, that , that they may be doing or not doing. So we want to get a clear idea of really what it is you're doing because , uh, the , uh , carrier is going to contact your employer about your occupational description, because you didn't insure your job, you insured your occupation. So we want to make sure that you and your employer are on board, or at least the carrier knows that you may be performing this job differently than your employer's own job description. Now that may not even matter if you're , if the definition of occupation is as it's performed in a national economy. So it really doesn't necessarily matter if your employer has you do something differently or admit something because the test is not going to be , uh, how you perform for your employer, but how it performs in a national economy. And if you've got that, then you need to get out this old book called the dictionary of occupational titles and try to find your occupation because that's what we have to prove that you can't do. You can't do the material and substantial duties of your occupation as defined by the disability insurance policy. Now the next form might be a training and experience form . Uh, and I , um, we'll generally see that particularly when the definition of disability changing from , uh, your occupation to any occupation, but that training and education experience form called a T and E is also , uh, an important form. And all these worms , you should be , uh , um , preparing accurately and completely. Now, if we are looking at a situation where your definition of disability is going to be changing, it's crucial that you understand the definition of sedentary occupation. Well, why is that? If the disability carrier determines that you can do sedentary work, their vocational evaluator will look at occupations that are both substantial and gainful, and that it's going to be the basis for a claims, denial, termination of your benefits. And it really doesn't matter if there's no employer that would hire you or perform any of the occupations that the, a vocational evaluator suggests that you could perform among the other important forms are the attending physician statement and sedentary restrictions and limitations information. Now, the carrier is going to throughout the life of your claim, ask your doctor to fill out what's called an attending physician statement form and APS form extensively. It's designed to ask questions about your physical restrictions, limitations, your psychiatric restrictions, limitations in any behavioral problems that you might have. The problem with these forms is that they're designed to have your physician indicate that you have restrictions and limitations such that you can work in some capacity, particularly if we are in this transition stage from own occupation to any occupation, because if you can do sedentary work, then your benefits are going to be terminated. You need to understand that these forms are not written in a way that allow the doctor to give an opinion that you're unable to work. Or even though you can only do sedentary work, they're designed to lead your physician down the path of saying that you can work in some capacity. Obviously that's a trick. Um, I supplement the attending physician statement form with the applicable residual functional capacity form that's found in a social security case. Yeah, I know that your case isn't a social security case. Well , it might be, but for example, if you have a cardiac condition, I can assure you that the APS form, isn't going to ask relevant questions about your cardiac symptoms and how their symptoms impact your ability to function. Yet. If you look at a cardiac residual functional capacity form for a social security case, it's asked questions about exertional impairments, non exertional impairments , um, difficulty walking, sitting, standing the impact of , uh , stress in the side effects of medications. These are all things that you'll not see a traditional disability carrier APS form ask . Now another form that is important is the activity of daily living form . I think that's a trap. It's an open-ended generic form that asks you to tell them what it is you do during the course of a day. Now you may do a range of things on a good day. You may do more than you do on a bad day. And the next day you may suffer from what you did on that good day. Um, I don't like these forms because they're, open-ended, I prefer to try to give ranges , um, of, of activity . So how much you can lift, sit stoop, bend that sort of stuff. But they're also using this to get information about what it is you do, you volunteer, do you garden, do you have any hobbies? What is it that you can't do anymore? Um, because ultimately this is a trap it's used in several ways. It's used in conjunction with the attending physician statement forms, and it's used in conjunction with your medical history. If there's a difference between what you're telling your doctor of what you can do about what a difference between what you put on your activities of daily living forms , um, that can set up a surveillance situation. It can also lead the carrier to say, we don't believe your doctor because you're telling us you can't do these things, but you're telling your doctor that you can, can do things that, that , uh , seem to be outside of your claim restrictions, limitations, or what the doctor has said that you could do. So these forms are used to create conflict, to attack the basis of the doctor's opinion and to put surveillance on you. Now, you are going to be probably asked to sign a release. Uh , there's some controversy about releases. You have a duty to cooperate, which means that you should be signing the release. I try to limit the release. How do I limit the release? I will limit in terms of scope , uh, and say you only , uh, we'll we'll sign a release, but you gotta put on that release. The names of the medical providers is going to, I generally don't like , um, my clients to sign open-ended , um, medical leases that don't identify who is going to go to. The second thing I try to do is to modify the release, to say that it's only valid for six months. And the third thing I try to do is to put on the bottom of it that says any and all information that you obtained via this release has to be forwarded to me. Now, I also let the doctor know that I'm limiting the release , um, so that my physicians aren't caught blind by a blanket request for information. So I'll tell them the release is only valid for six months. And I gave a release specifically to you , uh , and not a generic open-ended release. There's also some controversy about social security releases. This my carriers want to get a copy of your social security file. And I think quite frankly, they should. Why do I say that? Well, because I often argue as many at Reza disability lawyers do that as a carer denies the file. When they know that the claimant is getting social security, they have not done a full and fair review of your claim because they haven't gotten the necessary information that they need to evaluate the claim. Um, some people may say, well, that's confidential. Yes and no. What do I mean by that? Uh, it is got information about your earnings, your earnings records and what your social security benefits are. But at the end of the day, it doesn't matter because most disability policies say they have the right to reduce your benefits by the receipt of your social security benefits. So they're going to get that information one way or the other. I actually like to submit as part of any claim or appeal, the whole social security disability file from beginning dad, every piece of paper, my client filled out, which of course I've reviewed any information supplied by friends or relatives. Uh, the medical records, the attending physician statement forms , uh, the CMS, the , um, uh , actual decision of the judge. Um, why do I want that? I want them to have all of that information because I will take them to cask as have many courts for not for not considering that information. So I would rather give them that information , uh, so that they have the ability to obtain a copy of your social security file and to review it, if you want to limit what it is you're giving them access to you can, I don't think it's a very good idea because you have a duty to cooperate and more importantly, more often than not what's in that social security file is going to help case. What do I mean by that under the , uh , case law , um, MetLife versus Glenn , the United States Supreme court has said that a carrier has to take into consideration the social security decision and the information in the , uh , in the file. Now, sometimes it won't be fair . Well , sometimes the judge is going to say that you can work in a sedentary capacity, but because of your age, you grid out well, age is never a factor in a social security or an LTD case anyway, but the carrier is going to seize on that as a basis for denial. Um, as a seasoned ERISA disability attorney, I can get around that. I can address that through my vocational rehabilitation counselor and explain what the grids are, explain why the age is not a factor. And I explained that not withstanding the finding of the judge, that you can do sedentary work, that there are other conditions that the judge didn't necessarily consider in awarding that benefit or that , um, ultimately the judge did award the benefits, not withstanding the fact that you were in a sedentary capacity and explain what the judge did and what that means in terms of the LTD claim. I don't want the carrier to just seize on some bad information or bad decision. And I happens , uh, I want to be able to control the narrative, even in the situation of , uh , of , uh , a poor result in a social security case. I think not providing that information is just a recipe ultimately for disaster. Now, I also want you to understand that if you're a medical professional or a professional, like an attorney, you're going to be expected to provide financial information. And that includes tax returns and your monthly or quarterly financials. A lot of my clients get upset about that. And I say, well, why are we getting upset about that? Because you have a residual disability provision in your policy. That means that potentially if you've had an 80% loss of your over earnings , uh, based on your before monthly income, we're able to collect residual disability benefits. And to do those calculations, I have to look at your income tax return. I have to look at your monthly financials because I'm going to create a spreadsheet. So that explains why you're entitled to your residual disability benefits, if it does the math. And then I correlate it , of course, with your medical to confirm that you had restrictions or limitations as of that date, that will , um, impacts or impacted your ability to earn your , uh , disability wages. So I think that it's really it important that we produce that information and it is analyzed in a fashion that we can explain where the residual disability claim starts, where Anna's with a disability, a term disability claim starts. And I like to send all of this information if necessary together with the billing information and the CPT codes. So why do I want to do that? Because they're trying to determine what your occupation was at the time you became disabled, and they're going to do an analysis of your practice. So if you're a plastic surgeon, for example, they're going to want to know what different kinds of procedures you did, how, how many procedures you did, because as we develop the claim for residual disability benefits and total benefits, we want to show the nature of the change in the procedures or the number of procedures, fact that you might be making referrals. And of course that potentially can lead to them requesting your appointment book. I don't have a problem with any of this. I like to send it to them in a big shotgun , all box that goes thud when it hits their desk, because I've answered every one of their questions. We've got this winning claims application with all the forms. If we've got a residual disability claim, I've done all the calculations, I've got all the supporting tax and financial documentation. I've got the medical records, I've got a vocational report of necessary that ties it all down to a specific date . So really I think that a shock and awe application is the key to not only winning your benefits out of the box, but to maintain your disability benefits. You can see that putting together an application is not easy. It's not for the faint of heart. And it takes a lot of thought coordination and potentially calculations. Wow, that's a lot of information to absorb. So let's take a quick break. And when we return , I look forward to talking to you about what you need to know about the proof of claim forms that you will be sent. Alright , what you need to know about the proof of playing forms , you'll be sent by the disability carrier. Now, the requirements for the proof of loss are not the same requirements as providing notice. And so let me give you another example of a proof of loss provision in a disability policy, The petition and return of the claim form, or if needed the letter described in the notice of the claim section above will serve as a proper filing of proof of loss. That's really confusing, isn't it it's goes on to say this filing must be received in our office no later than 90 days after the end of the period, for which benefits are claimed benefits, won't be reduced to the delay and filing a proof of loss. If it was filed as reasonably as possible and no event where we accept the filing of proof of loss of more than a year after it's due. And that provision won't apply, if you weren't competent to make the claim. So you can see in these proof of forms or provisions, rather that there are timeframes in which they expect that you're going to be submitting this documentation. And if you don't submit it timely, they may say too bad. So sad. These provisions, as you can understand, based on what I just said are rather confusing. And so that's another reason why you want to get your disability policy out and read the provisions before you stop working and apply for benefits, because we want to really be on top of this game. We want to control , uh, when we're filing for disability, the quality of the disability application, and we obviously want to do it properly. So let's talk about what is properly. There are generally in a disability policy, a clause called proof of your claim, and it might say something about what it is. You have to submit as proof of claim. You need to really, really read this provision closely. You need to make sure you understand it thoroughly before you file your claim. Because for the most common reasons for denials of claims, I think are found in the proof of claim section. And I'm going to discuss that later under claims denial. So what is the typical proof of claim provision say, it says something like this, what information is needed is proof of your claim that you're under the regular care of a doctor, the appropriate documentation of your monthly earnings, the date your disability began, the cause of your disability, the extent of your disability, including restrictions and limitations that prevent you from performing your regular occupation, the name and address of any hospital or institution where you received treatment, including all attending forms , also all attending doctors. Now, the policy will probably go on to say that we can request that you send proof of continuing disability, indicating that you're under the regular care of a doctor. This proof is provided at your expense, and it has to be sent in within 30 days of the request by us. And again, you may be required to provide me the carrier with notice of any change in your medical providers. And we want authorization to get additional medical information. So we want proof of continuing disability, or we're going to deny your claim or stop sending your payments. If the appropriate information is not submitted well, that's a whole lot of language, isn't it? So let's break this down. What is regular care of a doctor mean? Well, there are two crucial parts of that definition, regular care and doctor. So once again, we've got to go get that policy out. Regular care could be defined as something like you personally, visit a doctor as frequently as medically required, according to generally accepted medical standards to effectively manage and treat your disabling condition. Now the day of telemedicine, I think that that will pass certainly during the era of COVID here, but the other key provision is as frequently as medically required, according to generally accepted medical standards, well, might come a time in your case where the doctor says, I don't need to see you as frequently. Um, I only need to see you every six months or once a year. I would be saying to you, man , you need to see the doctor at least every three months, because you want to be able to establish that you are , uh , treatment is , uh , and your condition is being effectively managed because that's another key provision in that definition. But there's more to that definition or regular care is defined as receiving the most appropriate treatment and care, which conforms to generally accepted medical standards for your disabling condition, by a doctor whose specialty or experience is most appropriate for your disabling condition. According to generally accepted medical standards, I have clients who want to try alternative medication and I get it, but I think that you have to have exhausted appropriate medical treatment and care before you try alternative medicine. If you go right to alternative medicine, I promise you the carrier is going to deny your claim. The other issue with this definition is a doctor whose specialty or experience is most appropriate for your disabling condition. So let's see. So you've got fibromyalgia. Should you be treating with a family doctor or a rheumatologist? Well, pretty clear you should be treating with a rheumatologist. So the carrier just might get bent out of shape because you're not being treated by the right specialist. So what does the word doctor mean? A person performing tasks that within the limits of their medical license, a person who's licensed to practice medicine prescribe and administer drugs or perform surgery, a person with a doctorate degree in psychology whose primary practice is treating patients, a person who has a legally qualified medical practitioner, according to the laws and regulations of the governing jurisdiction. And by the way, we will recognize you or your spouse, children, parents, or siblings as a doctor for any claim. So you've got to prove to the display carrier that you're seeing a physician as often as required for the diagnosis. And that can again be a problem. Particularly it's psychological claims, well claims involving depression or anxiety is , um, uh , a situation where depending on the severity of the , um , depression or anxiety might be as little as twice a month. So you might be seeing a qualified therapist, psychologist or psychiatrist, but you may not be seeing them as frequently as the carrier wants. And it's not uncommon for claims to be denied on the basis that the level of care you receive is not appropriate based on the frequency of the care, the lack of testing, the lack of participation, the lack of recommendation of counseling, including group theory therapy, the lack of counseling in combination with medications or referrals to other specialists. The problem with these definitions is that they're so broad that carriers use them as a licensed to create requirements that really don't exist in the terms of the policy. They kind of make up their interpretation of what regular care is as they go along, depending on what they want to do with your claim. Now, this will , the insurance carriers are going to routinely hire board certified in-house liar for hire physicians or peer review physicians who review your claim. It's guaranteed. And that's particularly true in psychiatric or psychological claim where there's a lack of documentation in your medical chart regarding the basis of the diagnosis. Uh, observations about your ability to function, which seem to be inconsistent with , uh , the restrictions and limitations that you're suffering and a lack of treatment plan. If you're not getting regular care, you can destroy your claim, even though you might have a problem , uh , paying for the care, you might have lost your group insurance. You might not be able to afford the medication. There may facilities that offer lower , no cost medical care that you should , uh , take advantage of. If you lose your health insurance, it's important that you get this medical care. Not only because it improves your medical condition, but it assists you in both your long-term disability claim and a social security disability claim. Now, remember the care has to be appropriate. I find often that doctor's records just don't document. The extent nature level of the kid is being required. And you've got a problem through no fault of your own, and it might be necessary to have your physician write a detailed letter for which they're going to charge you for that sets forth. The testing, they perform the care they're providing and confirm that the care that you're getting is appropriate based on your symptomatology. If your doctor refuses, it might be time to change a physician and find one that supports your claim and we'll document your file appropriately. Now, another provision in these policies is regular and ongoing medical care. They're going to continually ask you and your doctor to provide office treatment notes. That document not only you're seeing the physician on a regular basis, but that the care is appropriate. So let's talk about the definition of regular inappropriate care. We may request that you send proof of continuing disability, indicating that you're under the care of a doctor. This proof provided at your own expense has to be received within 45 days. And if you don't provide it to us, then we are potentially going to deny your claim. Now, again, this doesn't tell you what regular is. It doesn't necessarily tell you what appropriate is and you to figure it out because you're contractually obligated to provide proof of regular and ongoing treatment. So I would be sitting down with your doctor and saying to them, what is regular what's appropriate? And could you please document the frequency and the nature of the treatment you're recommending in , um, my medical records. Now, the other issue is going to be the date of visibility, the cause of disability and restrictions limitations. And we've talked about this before and while they like the APS forms, they really want to see the office treatment notes to document the ongoing proof of your treatment and your disability. Now carriers are going to request those records because they have a fiduciary duty to investigate your claim. Whether there is a statute now there's no contractual obligation for them to request the medical information on your behalf. So sometimes they do, but it really is at the end of the day, your responsibility to provide the carrier with proof that it needs to evaluate your initial claim and your ongoing claim. That includes what is the date of your disability? What's the cause of your disability? Do you have a herniated disc that causes tickling a numbness that runs down your leg that makes it difficult for you to sit more than 20 minutes? So they want to know the restrictions and limitations. You can see again, that it's really crucial that you're reading your disability insurance policy so that you understand what goes into the notice of claim. I'm putting you on claim or notice that I'm filing a claim. And what goes in that proof of claim form in terms of the diagnosis, the treatment, and any other documentation that the carrier wants to see to evaluate your claim. All right, you ready to take another break? When we come back, I'm going to discuss the role of doctors in your application for benefits.

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Nancy L. Cavey:

The role of your doctor and your application for benefits, helping you establish the date of disability, the cause of disability and restrictions and limitations. Look, doctors didn't go to medical school to practice disability law. They don't like necessarily long-term disability claims, workers' comp claims or social security claims. Um, but they are key to getting your benefits. They need to complete forms because they're the key to the receipt of and continued payment of your disability benefits. So, as I've said before, in other episodes, if your physician doesn't understand their role, there are three options. You can have an open discussion with your physician off the record about the requirements that you have to meet, to be entitled to your benefits. Explain that once, get those benefits, you have an obligation to get regular and ongoing appropriate care. And in order to get paid, you need to be seeing them at least initially about every eight to 12 weeks. You want your doctor to incorporate your active activities of daily living forms into your chart notes and to document in the chart notes of what they considered to be regular inappropriate care for your case. And I actually prefer that. Or in addition to that, you give a good interval history to your physician, between visits. I have a form called symptoms and functionality, and it , uh, reviews for the physician or summarizes for your physician, the symptoms that you've had between visits with examples of how those symptoms have impacted your activities of daily living. So you might have difficulty standing in front of the sink , uh , cooking or doing dishes. You might have difficulty lifting laundry. That's over 10 pounds. You want to make sure that's documented in your records. Now, if the physician doesn't support your claim or is not cooperative, I have to tell you to go find a new doctor. That doctor, that you're seeing might be the best doctor for the treatment of your condition. But if they don't support your claim, if they're not willing to cooperate, if they're not willing to document stuff, you've just killed your case. You need to really understand that if your doctor isn't supportive of your claim, your LTD claim, your social security claim, you're really putting your , uh, your whole claim at risk. I don't want you to drop out of medical treatment either. Even if your benefits have been denied or terminated, if your benefits are at issue, we're going to be filing an appeal saying that the decision was wrong. And by the way, you continue to be disabled because you're continuing to get medical care. And if the carrier reinstates your benefits, but then sees, you're not getting ongoing care, they're going to do the same game again. And they're going to say, Hey, you're not getting regular care as required by the policy. And so, even though you might be disabled, you don't meet the proof standard . So we're going to deny you benefits. So when you apply for your claim, there are three things that we want to be talking about. What's the date of disability. Now , that's pretty obvious if you've been in an auto accident, you know, the day that you were injured, but if you're having ongoing medical problems and you're working while you're disabled, it's important that you are working with your physician to pick the right date, to stop work. That can be a crucial date because if you're working and you're having trouble and you get terminated, the carrier is going to say too bad. So sad. You didn't have coverage on the date that you stopped working because you were terminated because you had problems and they terminate you for performance, and you were earning what you were making. So there's no lost wages. Um, if you can smell that coming, you want to get your doctor to take you out of work. Cause being hero can result in you getting no benefits. The next thing that's important is the basis of disability. You want your doctor to document a be objective basis of the diagnosis and the objective basis of the restrictions limitations. Now you've heard me use that word objective. You didn't hear that in any of the proof of plane provision forms that I talked about earlier, but the reality is that your claim is going to be denied. If there isn't any objective medical evidence to establish the basis of the diagnosis. So that might be lab reports, x-rays MRIs , CT scans, surgical reports, EGS cardiac, or stress tests , any other medical testing you have that shows that you have the disease that your physician has diagnosed you with. Now, I know that can be problematic and conditions where there's no known test or objective data available. Your physician might have to make a clinical diagnosis based on your physical examination. And that might be in this situation of a Lyme disease case, fibromyalgia, RSD, depression, Ms. Pseudo seizures , all sorts of diseases that in their initial stages, don't necessarily present with objective findings on diagnostic testing. Now, while carriers might ultimately accept your conditions such as Lyme disease or fibromyalgia as a diagnosis, they just may pay those benefits on a self-reported limitation, well provision of 24 months. And you need to be aware of that again in your policy. But again, the medical evidence is crucial as it relates to your restrictions and limitations. So the carrier might say, look , uh , I agree, there's no objective diagnostic testing for fibromyalgia, but we do expect that there are objective findings or a reason for those restrictions and limitations. And the courts will support them. The courts say, okay, we get it. There are some medical conditions where there's just no objective testing, but we do expect that there'd be an organic and objective basis for the restrictions and limitations. That's crucial. Uh , particularly if you are having problems with multiple sclerosis, fibromyalgia, limes to Lyme disease, there are two ways we can go about this. Maybe three ways. We can get a functional capacity evaluation. If your physician isn't willing to address your restrictions, limitations, or explain them, but we can get a C pet testing, which will document the exhaustion and fatigue , um, that results in these , um , conditions. And it can cause restrictions and limitations. And we can also have necessarily get our own independent medical evaluation that will provide a physical basis or organic basis or explanation for the assigned restrictions limitations. You can see that , um, restrictions and limitations aren't defined in the terms of your policy, but restrictions are considered to be those physical or mental activities that you can't do because of your physical or mental impairment. So for example, if you have a herniated disc, you might be restricted from lifting more than a half a gallon of milk. Now, on the other hand , um, you might have what's called non-international restrictions and limitations, which is the need, for example, to alternate sitting and standing, or to have to take breaks or to elevate your legs. These again, also have to be objectively , um, diagnosed. And what you'll see in, in policy language is something like this eye condition in and of itself doesn't necessarily equal disability and conditions may improve stabilize or worsen over time. Therefore, our ongoing consideration of your claim includes updated medical information, reviews, relevant and appropriate, including the right to an independent medical evaluation. So that's their language to deny claims on the basis that your diagnosis doesn't equal impairment or that the restrictions of limitations aren't objectively based and they don't equal impairment. Now, disability companies use certain defense doctors who I call liar for hires, but there's also a company that has developed disability duration guidelines. You need to understand that they don't incorporate that in the disability policy, but they use these rigid and inflexible guidelines to say, Oh, you've had a herniated disc. You've had surgery. According to our guide, you should be back to work in six months. And so if that's happening again, you want to be using a functional capacity evaluation or an IME to establish the extended nature of your restrictions and limitations. Now, again, there's going to be this causal relationship between the diagnosis and the restrictions limitations, and the inability to do your own occupation, because you can have a diagnosis, but that doesn't mean that you can't do your own occupation. Just thinking about the number of NFL football players are out there with herniated disc still playing football. So we've got to connect the , uh , disability diagnosis , uh , and or the restrictions limitations to your inability to do your own occupation if we're at the own occupation stage. And one of the ways to do that of course, is to obtain what's called a vocational evaluation opinion. A vocational evaluator is an expert in the world of work, and they understand what the restrictions and limitations are. They understand what the occupational duties are, and they can say, Hey, I've reviewed the medical records. I've reviewed the activity of daily living form. I review the client's occupational description for when the employer's description of the occupation. I don't think that the applicant can do the maternity substantial duties of the occupation, including these duties. One, two, three, four, five. And this is why from a vocational standpoint, I don't think that they can do these duties. So the vocational evaluator can tie together the diagnosis , uh, and the restrictions limitations to show that you're unable to perform a material and substantial duties of your own occupation. Once again, you can see there's a lot of thought and effort that goes into putting together a winning application. It starts with a review of the policy. It starts by understanding what's in your medical records or what needs to be in your medical records. And it really involves an analysis of what's there, what needs to be developed or proven to submit a winning application. And then of course, putting together that shocking all application package that gives the carrier , um, no reason to doubt your claim, no reason to contest your claim, and every reason to issue a check to you and send it to you as quickly as possible. All right , that's a wrap. If you like this podcast, consider liking our page, leaving a review or sharing it with your friends and family. This podcast comes out weekly. So tune in next week for another episode of winning, isn't easy.