The Ongoing Proof Trap: When Improvement, Doctors, and Daily Activities Kill Your Long-Term Disability Claim

Welcome to Season 6, Episode 6 of Winning Isn't Easy. In this episode, we'll dive into The Ongoing Proof Trap: When Improvement, Doctors, and Daily Activities Kill Your Long-Term Disability Claim.

Securing ERISA Long-Term Disability benefits often hinges on a hidden danger: the ongoing proof required to keep them. Insurers don’t just assess whether a condition exists - they look for signs of improvement, weigh treating physician opinions, and scrutinize everyday activities for evidence you can still work. Even minor changes in medical records, mixed messages from doctors, or routine daily tasks can quietly undermine a valid claim. In this episode, we break down how perceived improvement, physician dynamics, and lifestyle details are used to challenge continued eligibility. By the end, you’ll understand why maintaining LTD benefits isn’t just about proving disability once - it’s about consistently documenting functional limits and avoiding the traps that lead to termination.

In this episode, we'll cover the following topics:

One - When Improvement in Cardiac Function Can End Your Benefits

Two - When Your Treating Physician’s Opinion Doesn’t Guarantee Your Claim

Three - Daily Activities That Can Kill Your ERISA Disability Claim

Whether you're a claimant, or simply seeking valuable insights into the disability claims landscape, this episode provides essential guidance to help you succeed in your journey. Don't miss it.


Listen to Our Sister Podcast:

We have a sister podcast - Winning Isn't Easy: Navigating Your Social Security Disability Claim. Give it a listen: https://wiessdpodcast.buzzsprout.com/


Resources Mentioned in This Episode:

LINK TO ROBBED OF YOUR PEACE OF MIND: https://mailchi.mp/caveylaw/ltd-robbed-of-your-piece-of-mind

LINK TO THE DISABILITY INSURANCE CLAIM SURVIVAL GUIDE FOR PROFESSIONALS: https://mailchi.mp/caveylaw/professionals-guide-to-ltd-benefits

FREE CONSULT LINK: https://caveylaw.com/contact-us/


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Need help with your Long-Term Disability or ERISA claim? Have questions? Please feel welcome to reach out to use for a FREE consultation. Just mention you listened to our podcast.

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Please remember that the content shared is for informational purposes only, and should not replace personalized legal advice or guidance from qualified professionals.

Transcript

Speaker A [00:00:15]:
 Hey, imagine receiving your long-term disability benefits for your years only to have them suddenly terminated because your condition has improved. Or because you were caught bowling on the weekend. Hmm, sounds unfair, right? Yet this is the reality for many ERISA disability claimants. Hey, I'm Nancy Kaveh, National ERISA and Individual Disability Attorney. Welcome to this episode of Winning Isn't Easy. Before we get started, I've gotta give you that legal disclaimer. This podcast is not legal advice. The Florida Bar Association says I have to tell you that.
 
 Speaker A [00:00:51]:
 And now that I've done it, nothing will ever prevent me from giving you an easy-to-understand overview of the disability insurance— world, the games that disability carriers play, and what you need to know to get the disability benefits you deserve. So off we go. Understanding the long-term disability claims process under ERISA can be the difference between maintaining your benefits you've paid for and having your claim unexpectedly denied or benefits terminated. Now, insurance carriers or plans aren't just looking at your diagnosis. They're examining your functional abilities, your treating physician's opinions, and even what you do on day-to-day basis. And by the way, what they catch you doing or posting about on social media sites. I will tell you that small shifts in medical records, subtle changes in your lifestyle, conflicting opinions from doctors, and all that stuff on social media can put your benefits at risk. In today's episode, I'm gonna talk about 3 things.
 
 Speaker A [00:01:50]:
 First, I wanna talk about how Improvements in your medical condition can impact your claim. Two, I wanna discuss the role of your treating physician and how carriers weigh their opinions. And finally, I'm gonna talk about the ways that your daily activities can undermine your claim, resulting in a denial or termination. By the end of this episode, my goal is that you will see that securing long-term disability benefits and maintaining your claim is not just about proving you're sick, it's about managing the ongoing documentation and perceptions of your functional limitations. I'm gonna talk about 3 things. Number 1, when improvement in cardiac function can end your benefits. Number 2, when your treating physician's opinion doesn't guarantee your claim and what will happen. And 3, how daily activities can kill and destroy your erisa disability claim.
 
 Speaker A [00:02:47]:
 Now, before we get started, I wanna take a break, and I would urge you to come back with a pad and a pencil so that you can take notes, because this is crucial if you want to stay on claim. All right, let's take a break.
 
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 Speaker A [00:03:42]:
 today. Welcome back to Winning Isn't Easy. When improvement in your cardiac function can result in a termination of your benefits. Now, it's just not improvement in cardiac functions, it's improvement in any of your medical conditions. So just because your disability carrier plan has accepted your disability insurance claim doesn't mean that you're going to remain on payment throughout the life of the claim or the life of the benefit period. You, you, and you have the burden to prove every month that you continue to meet the disability requirements typically found in the policy. They, the carrier of the plan, don't have the burden of proof. You have the burden of proof.
 
 Speaker A [00:04:23]:
 So let me give you an example in the case of Stout versus Smith International. Stout was an offshore drilling engineer who was diagnosed with a heart condition in 2011. And as you can imagine, he was restricted to no lifting more than 25 pounds. His work as an offshore drilling engineer required lifting twice that amount. So he was paid benefits under Smith's disability plan that was offered and administered by MetLife. So, so far so good. Well, guess what? In 2021, MetLife obtained medical records showing improvement and documenting that his valvular heart disease was stable. And boy, that set off a continuing disability review.
 
 Speaker A [00:05:06]:
 MetLife's liar-for-hire doctor concluded that Stout's cardiological condition had in fact improved and that there weren't any restrictions and limitations on his functioning. So MetLife shared this report with the treating cardiologist, who agreed that Stout was able to work. In fact, his cardiologist not only agreed with MetLife, but opined that Stout could return to full-time work. Now, I will tell you, that does not help your disability claim if your physician changes their opinion about your ability to work. And as a result, the benefits were terminated after being paid for over 10 years. Stout appealed, and as part of the appeal process, MetLife had a second physician review the records, and that second physician concluded that the cardiac impairments were not severe enough to impair Stout's ability to work, and there weren't any restrictions and limitations. MetLife appealed the termination of the benefits, and guess what? This case ends up in federal court, and the district court granted summary judgment for MetLife But he didn't give up. He went to the Fifth Circuit, and they summarily upheld the termination of benefits, opining, there is no evidence in the administrative record that Stout is disabled.
 
 Speaker A [00:06:20]:
 All three doctors who examined Stout and reviewed his medical records concluded there weren't any restrictions and limitations. And with no evidence of restrictions, limitations, no reasonable fact-finder could find that he was unable to earn 60% of his predisability earnings, and therefore he's not entitled to his benefits. So I think there are some important lessons here. One, benefits don't continue forever. Two, policyholder— plan beneficiary has the burden of proving entitlement. Number three, without the support of your provider, your claim is doomed. Number four, if your physician no longer supports the claim, you need to find a new treating physician. Now, as part of if you will, 4 and 5, I would suggest that you send a letter to your treating provider that says, you do not have permission to speak with the disability carrier's physicians, and you must send to me any and all correspondence you get from the carrier inquiring about my medical status.
 
 Speaker A [00:07:24]:
 And before you reply to the same I would like to have a consultive examination with you to update you on my medical status. Now, the, the next suggestion is, of course, finding a new medical provider, and that is something that you quite frankly should know sooner than later. So you should probably ask your provider on a regular basis, do you still support my claim? And if they start hedging around or won't answer the question, that's all you need to know to go find a new doctor. Now the other thing that you might want to do is secure your own independent medical evaluation to address your restrictions and limitations and perhaps have some cardiological testing or applicable testing that will measure your functionality. That could be cardiological testing. If you have a heart condition, it could be a functional capacity evaluation. But what you want to do is establish an objective basis for those restrictions and limitations. But I want to discuss with you something very important, and that's the concept of improvement.
 
 Speaker A [00:08:34]:
 Now, what I tell my clients is this: I have a formula that I want you to apply, uh, and I want you to use this formula when you are seeing your doctor giving interval histories. And the formula is this: symptoms plus The location of your symptoms plus the nature of your symptoms plus the duration of your symptoms plus the frequency of symptoms equals functionality. So in this particular case, I would have suggested that the claimant be giving a history of what his symptoms might be. So it might have been that he continued to have shortness of breath with or without exertion. He might have continued to have problems with walking. He might have had problems having to elevate his, his feet, whatever his problems were. And I would be discussing the nature of those symptoms, location, frequency, and duration. And I would be giving the doctor examples of problems with functionality.
 
 Speaker A [00:09:42]:
 The other thing that I would be discussing with the doctor is the concept of improvement. Many people will go into the doctor's office and the doctor will say, well, how you doing? And you'll say, I'm fine, or I'm better, or I'm improved. Please don't use those words. We want to have you explain your symptoms in a way that documents your functionality. Okay. Now, if there's been improvement, we need to discuss, or you need to discuss, the nature of that improvement. Is it temporary? Is it permanent? If it's permanent, what has been the actual nature of the improvement in terms of your symptoms or functionality? And give an example. And it might be that you have some improvement, but you still can't do the material and substantial duties of your occupation.
 
 Speaker A [00:10:32]:
 Or if you're at the any occupation stage, that you can't do the material and substantial duties of any occupation. So it really is incumbent upon you to give a really good interval history, be careful about the words that you use, and of course, know where your doctor's head is at. So what happens when your treating physician changes their mind, or when the carrier discounts their opinion entirely? That's what I'm going to explore next— how insurance companies evaluate treating physicians and why their deference or lack of deference to the opinion of your treating physician can make or break your claim. Let's take a break. Welcome back to Winning Isn't Easy. When your treating physician's opinion doesn't guarantee your claim. Now, you may have gotten an ERISA denial letter or termination of benefits letter and noticed that they don't really explain why they didn't really fully consider the opinions of your treating physician. And you may wonder what's wrong with that.
 
 Speaker A [00:11:51]:
 Now, I would love to tell you that a carrier plan's failure to explain why it didn't credit the opinion of your treating physician is flat out wrong. Unfortunately, it isn't. In ERISA, the statute does not require the carrier, the plan administrator, to give special deference to the opinions of treating physicians. In other words, they're not required to accept the opinions of your doctors over their liar-for-hire doctors. And as a result, that's a problem. Courts also generally don't impose a burden on a plan administrator or the carrier to explain why they credited reliable evidence that conflicts with the treating physician's opinion. But there are ways to attack this, particularly if the carrier or the plan— or the carrier plan's doctors don't have all the evidence to review, have misconstrued it, made speculative comments about the basis of the opinions. Uh, so there are ways that we can attack the lack of deference.
 
 Speaker A [00:12:50]:
 Now Why? And that's because the disability carrier plan administrator can't arbitrarily refuse to credit reliable evidence, including the opinions of your doctor. But they don't have to do a blow-by-blow explanation as to why they disagreed with the treating physician, line by line, etc., etc. Now, that's particularly true in situations where the medical reviewers decline to give weight to the policyholder's subjective complaints. And so I will tell you I read denial and termination letters every day where the carrier, the plan doctors say there's no objective evidence supporting the treating physician's opinion. Now, when the carrier or plan issues the denial letter, the case law is really clear. They do have to review and weigh the opinions of the treating physicians. They don't necessarily have to devote specific pages of the denial or termination letter explaining why they disagree. Now, courts have even gone so far as to endorse carriers including summaries of other medical reviewers in the denial letter than rather them engaging in an independent analysis.
 
 Speaker A [00:13:55]:
 And I think that's unfair, but courts have ruled otherwise. So again, that is something that I do attack in my own fashion, because many times we will find that the summaries of the medical reviewers isn't accurate. So I argue, among other things, that if the doctor didn't have all the medical evidence, if the summary isn't accurate or complete, or if they cherry-pick the medical records, then the carrier plan's reliance on that particular review and the reviewer's conclusions is what's called arbitrary and capricious. And I argue that they really didn't engage in independent analysis. So in short, when you receive a denial termination letter, please don't expect a line-by-line analysis of what your doctor said and what their doctor had to say about it. I know that's frustrating, but again, it's something that we will use in the course of writing our appeal letter, because as we generally look at these records, we see that they didn't have all the records, or they didn't consider material information, or that they cherry-pick the medical records. And so we don't ignore it, we analyze it in a different fashion. Now, your doctor's opinion alone is not going to be a guarantee shield.
 
 Speaker A [00:15:15]:
 And if you're getting a denial or termination letter, you've got 180 days in which to file an appeal. That is really crucial because it's the trial of your case. So we may want to go back to your treating physician and get a statement from them as— and have them specifically address what the liar-for-hire doctor had to say, or you might undergo functional evaluation tests or other studies to rebut the opinion of the medical peer reviewer. You might even want to have an independent medical evaluation and have that medical evaluator address and rebut line by line why the liar-for-hire peer review doctors are wrong. And then we incorporate that into our appeal letter also attacking the legal reasons why that peer review medical report is wrong. So because your records are going to be cherry-picked, you also need to understand that they're going to be cherry-picking the Activity of Daily Living forms that you're completing, uh, and they're going to be looking on a regular basis at all sorts of social media sites, including gaming sites. So exactly how those seemingly changes in your— harmless changes in your activity or what you're doing or what you're posting on social media destroy your disability claim. And I will tell you, it happens in an instance, and I think this is crucial.
 
 Speaker A [00:16:37]:
 So let's take a break, and we're gonna come back and talk about the reality of how daily activities can kill your erisa disability
 
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 Speaker A [00:17:41]:
 Welcome back to Winning Isn't Easy. Let's talk about how daily activities can kill your ERISA disability claim and how social media can be the death— I mean, that, like, the final nail in the coffin, if you will. Now, I shouldn't be surprised at some of the things I find in my clients' medical records that destroy their claim, and that happens in a hot New York minute. Let me give you some examples of things that we have seen in records that just cause me not only a heartburn, but it's like, oh my God. Um, so let me give you some examples. The patient is doing better. He has gone skydiving for the first time last week. Well, he just, you know, drove his claim into the ground.
 
 Speaker A [00:18:26]:
 The patient has resumed bowling. The patient who has a back injury has resumed bowling. The patient went to a water park with her grandchildren and walked around all day and did the rides with her grandchildren. Problem with the hip, problem with the back, destroyed her case. So let me assure you that disability carriers and plans review your medical records with a fine-tooth comb and seize on statements like that to deny or terminate benefits. Skydiving probably means you can work. Walking in the park, riding attractions probably means you can perform most occupations. Bowling probably also perform most occupations.
 
 Speaker A [00:19:05]:
 Now, what are they going to do with that? They're also going to look at your activity of daily living forms. They don't ask you what you're doing just because they're interested. They're looking for you to create inconsistencies between what you're telling the doctor, even if you're making— not making silly comments like that, and what's in your activity of daily living forms, because they're looking for inconsistencies. If they find inconsistencies, you're going to be flagged for surveillance, and certainly that's going to result in a higher level of scrutiny because they're also going to have the investigator do social media searches. I have a case right now where there was surveillance twice and social media checks twice. The social media checks are over 75 pages. They, they check every site you could ever think of, including gaming sites. And there is a report by practically, I think, every social media site There exist many I never heard of.
 
 Speaker A [00:20:07]:
 So don't do that, because what the carrier is going to do is take that surveillance or the social media and share it with your doctors and say, hey, you know, look, we think there's some inconsistencies, or there's evidence of higher functionality. Now, most physicians are going to change their opinion when confronted with these inconsistencies or observations, regardless of how long they have treated you, or regardless of how friendly you think they are to your claim. It's gonna be the kiss of death for your disability claim, and it will be very hard to overcome. So if you are claiming disability benefits, number one, turn off your social media. Number two, tell your kids, family, or friends not to do any posting of meemaw while you're at the park or whatever else you're doing. Even something innocuous as birthday parties— no posting. No posting, no posting. Now, please don't do stupid things like skydiving, going to water parks, or anything you shouldn't be doing.
 
 Speaker A [00:21:07]:
 And of course, when asked by your physician about what it is you're doing, be mindful of how you're reporting that. Remember I talked about in the last segment my formula: symptoms, location, duration, intensity, and frequency of the symptoms. Equals functionality. Don't go in and say, ah, you know, I went to Disney with my grandkids this week. What you're going to talk about is your symptoms and your functionality, not necessarily your activities. Okay, oversharing with your doctor, oversharing on social media, oversharing with the adjuster in that innocuous 'how are you doing' phone call can destroy your claim. You can see that securing and maintaining long-term benefits is not just about proving that you're sick or disabled. It's about continuously documenting your limitations, managing your treating physician's opinions, and carefully but accurately presenting your day-to-day activities.
 
 Speaker A [00:22:08]:
 Understanding the proof trap that carriers or plans set, whether it's through improvement in condition, conflicting evidence, or your own activities of daily living, it's essential that you are going about it correctly and that you are doing so in a way that protect your benefits from denial or termination. Clearly, navigating ERISA is a complex journey, but with the right knowledge and the right strategy, you can strengthen your case and safeguard the benefits you've earned. So that's a wrap for today's episode of Winning Isn't Easy. Thanks for tuning in, and if you found this episode helpful, please take a moment to like our page, leave a review, share it with your family, and subscribe to this podcast. Join us next week for another insightful episode of Winning Isn't Easy. Thanks for listening.