Long COVID and ERISA Disability: Avoiding Denials and Proving Your Claim

Welcome to Season 6, Episode 9 of Winning Isn't Easy. In this episode, we'll dive into Long COVID and ERISA Disability: Avoiding Denials and Proving Your Claim.

Long COVID ERISA disability claims are often decided by how insurance carriers evaluate medical evidence and functional limitations. Symptoms like fatigue, brain fog, and shortness of breath can be debilitating, but insurers frequently argue they lack sufficient objective proof. As a result, claims may be delayed or denied even when the condition clearly affects a person’s ability to work. Carriers don’t just look at the diagnosis. They analyze residual functional capacity, compare medical restrictions to the duties of the claimant’s occupation, and sometimes argue that those skills could transfer to other jobs. If medical records or functional assessments aren’t clearly documented, insurers may claim the evidence fails to meet policy requirements. In this episode, we break down three issues that commonly affect long COVID ERISA disability claims: mistakes that cause claims to fail, how pre-existing condition provisions can limit coverage, and why challenging denials with stronger medical evidence is often critical to protecting benefits.

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

One - How to Lose Your Long COVID ERISA Disability Insurance Claim

Two - Court Upholds Unum Denial of Long COVID / POTS ERISA Disability Benefits

Three - The Importance of Challenging Every Reason for a Long COVID ERISA Long-Term Disability Denial

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

Nancy Cavey [00:00:11]:
 Hey, I'm Nancy Cavey, national ERISA and individual disability attorney. Welcome to Winning Isn't Easy. Before we get started, the Florida Bar Association says I have to give you a legal disclaimer, so here it is. This podcast isn't legal advice. Now that I've said that, nothing will 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 how ERISA disability carriers evaluate Long COVID claims can make the difference between receiving your benefits that you paid for and having your claim unfairly denied or benefits terminated. I will tell you that most disability carriers are not just looking at the diagnosis of Long COVID.
 
 Nancy Cavey [00:01:00]:
 What they're trying to determine is your residual functional capacity. In other words, whether you can perform your own occupation, and if you're at the any occupation stage, whether you can do any other occupation, as those terms are defined by your policy or plan. Now, I will tell you that Long COVID claims are especially tricky. Because many of the symptoms like fatigue, brain fog, and shortness of breath are subjective. The key to these claims are showing objective evidence of functional limitations that the symptoms create, and that's why understanding how disability carriers plan, evaluate claims, meet proof, determine if you're meeting the proof requirements, and addressing every reason in the denial or termination is crucial. So in today's episode, I'm going to break down the common mistakes that cause long-term disability claims to fail, including misunderstanding proof requirements and standards of review, how disability carriers might rely on a preexisting condition to deny claims, and why short-term disability benefits don't necessarily guarantee the payment of long-term disability benefits for Long COVID. And then I'm going to talk about the importance of challenging every denial and building objective medical evidence, as illustrated through federal court cases. By the end of this episode, I want you to see that winning a Long COVID ERISA claim isn't just about your medical condition.
 
 Nancy Cavey [00:02:27]:
 It's about clearly documenting your functional limitations, understanding the review process, and holding them accountable for making the correct decision. So let's dive in. I'm going to talk about first how to lose your long-term disability ERISA COVID claim, 2, how one court upheld Unum's denial of long-term COVID POTS Arisa disability benefits. And number 3, the importance of challenging every reason for Long COVID Arisa long-term disability denials or termination of benefits. When you come back, please bring a pad and a pencil because we're going to be outlining for you the things you need to know to get your disability benefits. But before you do, let's take a quick break.
 
 Speaker B [00:03:14]:
 Have you been robbed of your peace of mind by your disability insurance carrier? You owe it to yourself to get a copy of Robbed of Your Peace of Mind, which provides you with everything you need to know about the long-term disability claims process. Request your free copy of the book at kvlaw.com today.
 
 Nancy Cavey [00:03:53]:
 Welcome back to Winning Isn't Easy. How to lose your Long COVID ERISA disability insurance claim. Have you or a loved one been diagnosed with Long COVID? Are you covered under an ERISA disability policy or plan? That would provide disability benefits if you're unable to work. Do you want to know how to win a Long COVID Arisa Disability case? So I'm going to work backwards here because I'm going to tell you the reasons why people lose their claims. That'll give you a good foundation for winning a claim. Now, the number 1, number 2, and number 3 reasons are these. Number 1, no objective evidence of the Long COVID diagnosis. Number 2, No objective basis of the functional restrictions, limitations.
 
 Nancy Cavey [00:04:38]:
 Number 3, no causal relationship to an inability to do your own or any occupation. Now, I think one of the good ways to understand Long COVID cases are litigated cases where the federal courts have made decisions. You can see what the carriers have done and understand the court's analysis. Now, Now, in the case of Schwengel v. Hartford, the disability carrier Hartford argued that Schwengel wasn't due benefits because he didn't provide objective evidence for his Long COVID and didn't provide objective evidence of his subjective symptoms, such as fatigue and brain fog. Now, what happened ultimately is that the— that that argument didn't go very far, unfortunately, with this particular court. Now, what we find is that even if symptoms are subjective, functional limitations caused by these symptoms have to be objectively measured, and it isn't arbitrary and capricious to ask for objective evidence of the functional limitations. And so while it really wasn't an issue about the diagnosis.
 
 Nancy Cavey [00:05:53]:
 Where Schwenkel ran into difficulty was because there wasn't an objective basis of the restrictions and limitations. I think that part of the reason that she lost was starting with the standard of review. There are two possible standards of review in an ERISA disability case, and the first is known as the arbitrary and capricious standard, which restricts, restricts the court's ability to overturn a denial of benefits, even if the court disagrees with the decision. This standard asks whether the decision to terminate or deny benefits was reasonable and supported by evidence, not whether the decision was right or wrong. The second standard is known as the de novo standard of review, and that allows the court to make an independent decision. And I think if the de novo standard applied in Schwanke's case, she would have won., but she was stuck with the arbitrary and capricious standard of review. The second problem in the Schwangle case, and I think it is common to every kind of case, is not understanding the proof requirements of the policy or the plan. So there is no uniform terminology for proof requirements.
 
 Nancy Cavey [00:07:11]:
 Many policies or plans will require satisfactory proof. What is satisfactory proof? Well, that'll depend on the terms of the policy of the plan. And in Schwenkel's case, satisfactory proof required cooperation of subjective symptoms with objective medical and diagnostic testing. So just because you report your restrictions and limitations or your doctor assigns them doesn't mean that that automatically will satisfy the plan's definition of proof. So it wasn't so much the objective basis of the diagnosis that was the issue, it was the proof. So even when symptoms are subjective, functional limitations caused by those symptoms have to be objectively measured, and courts will often hold that it's not arbitrary and capricious to ask, particularly if the policy says so, for evidence of restrictions and limitations caused by those symptoms. Now, in Schwenkel's case, her pulmonary function tests were essentially normal. And the only significant objective medical evidence was cognitive testing.
 
 Nancy Cavey [00:08:18]:
 But unfortunately, that showed normal functioning and no impairment. And in her particular case, she was oriented to time and place. And I think that, quite frankly, is not a measure of cognitive functioning., but that was a failure of proof. And in Schwenkel's case, the carrier suggested that she submit additional evidence, and she ignored that. They suggested that she could provide additional testing, including formal neuropsychological testing, and she failed to follow those recommendations. And the court was not happy with that. So, what the court was looking for, as was Hartford, was objective evidence to corroborate the subjective nature of her complaints and inability to do her own or any occupation. I think that Schwengel made a big mistake by relying on her treating physician's opinion, because they're not automatically decisive.
 
 Nancy Cavey [00:09:17]:
 There is no treating physician rule under ERISA, and in fact, in this policy, Hartford had the ability to accept or reject the opinions of the treating physicians if those opinions were based on her subjective complaints. Now, she submitted pulmonary testing, which was normal. She submitted psychiatric questionnaires without testing. She submitted treatment records that didn't address the objective basis of the restrictions, and her own affidavit attesting to her subjective restrictions, limitations. But there was nothing objective about any of that, and the court concluded that Hartford reasonably considered that information in its decision to terminate benefits and upheld the denial. So considering those points, what happened was that the court found that Hartford's decision to terminate her benefits was reasonable and supported by the evidence and not arbitrary and capricious. So the key takeaway: 1, understand the terms of the disability insurance policy or plan. What is your burden of proof? Do you have to require— are you required to provide objective evidence of the diagnosis, objective evidence of the restrictions and limitations? Number 2, how are you going to go about doing that? What testing would document the nature of your symptoms that would establish that, one, they exist, but two, they're of a severity that would preclude you from doing your own work or any work if you're at that stage? Number 3, you want your physicians to corroborate that your subjective complaints are consistent with the nature of the disease, consistent with the nature of the testing, and if they're not, explain why they're not, but objectively based.
 
 Nancy Cavey [00:11:04]:
 And then lastly, of course, explain from an objective basis how they arrived at your restrictions and limitations and relying on your subjective complaints isn't going to cut it. Got it? Let's take a break. Welcome back to Winning Isn't Easy. Court Upholds Unum Denial of Long COVID POTS Arisa Disability Benefits. Now, Unum, like most disability insurance companies, is not in the business of paying long-term disability benefits. Particularly Long COVID sufferers who also have POTS, or postural orthostatic tachycardia syndrome. And in, I think, about early 2026, we're going to be doing another series involving 3 recent UNUM cases involving a denial or termination of Long COVID cases, because they are one of the primary offenders, if you will, in the denial or termination of Long COVID claims. So one of the first denial strategies that carriers will use is to look for a preexisting condition clause that will allow them to exclude from coverage any preexisting condition clause.
 
 Nancy Cavey [00:12:23]:
 So the disability policies or plans that have a preexisting condition clause will allow a carrier or plan to deny claims if the insured or the plan beneficiary received treatment for the same condition within a certain period of time before they obtained the policy. So let me give you an example. This is the case of Godwin v. Unum Life. It's a Sixth Circuit case in May of 2025, and Godwin was a nursing assistant who contracted COVID-19. She applied for her short-term disability benefits due to shortness of breath, chest pain, and POTS. Unum paid her short-term disability benefits but denied the long-term disability benefits, claiming that her POTS-induced dizziness was preexisting. Well, Godwin had been seen at the Cleveland Clinic where she had been diagnosed with POTS, and her treating physicians opined she couldn't return to work.
 
 Nancy Cavey [00:13:16]:
 But Unum's physicians, in looking at her medical history, noted that the vertigo diagnosis was preexisting. And as a result, since she had seen a doctor within a certain period of time before the coverage became effective and got treatment, said, hey, this POTS, this dizziness is excluded because her medical records documented treatment for vertigo during what's called the look-back period. So the Sixth Circuit ultimately upheld the denial in part due to this preexisting condition clause. Now, this clause was not in the short-term disability policy or plan. It was in the long-term disability policy or plan. So an important reminder here is that just because a disability carrier pays short-term disability benefits doesn't mean that they're legally obligated to pay long-term disability benefits. The policy terms, um, new medical testing, lack of objective evidence, and other factors can also be the basis for justifying a carrier's denial of long-term benefits for Long COVID because they've got lots of tools in their denial or termination toolbox, which we'll be talking about. So in the next episode of this podcast, I'm going to talk about the importance of challenging every reason for a Long COVID or risk of long-term disability denial, and you'll learn about some of these tools in the carrier denial or termination toolbox.
 
 Nancy Cavey [00:14:42]:
 Got it? Let's take a break.
 
 Speaker B [00:14:44]:
 Are you a professional with questions about your individual disability policy? You need the Disability Insurance Insurance Claims Survival Guide for Professionals. This book gives you a comprehensive understanding of your disability policy with tips and to-dos that will assist you in submitting a winning disability application. This is one you don't want to miss. For the next 24 hours, we are giving away free copies of the Disability Insurance Claims Survival Guide for Professionals. Order yours today at disabilityclaims.com.
 
 Nancy Cavey [00:15:38]:
 ClaimsForProfessionals.com. Welcome back to Winning Isn't Easy. Let's talk about the importance of challenging every reason for a Long COVID ERISA long-term disability denial or termination? Well, I have to tell you that unfortunately COVID is still with us. I actually got my updated COVID vaccination this week because, quite frankly, I don't want to get COVID. I represent too many people who have COVID, and I see firsthand the medical problems they have, but also the difficulty they have in obtaining their ERISA disability benefits due to proof issues. Under an ERISA disability policy, you, or a plan beneficiary, bear the burden of proving that you meet the elimination period and the policy's definition of disability. So I wanna talk about the case of Mendoza v. First Unum Life, which is a case out of the Southern District of California.
 
 Nancy Cavey [00:16:29]:
 Mendoza was hospitalized in January of 2021 for COVID-like symptoms, including lung inflammation, severe hypoxia with saturation levels as low as 70%, and ventricular systolic dysfunction that caused his heart to pump ineffectively. Now, surgery improved his cardiac function, but he continued to have reduced physical stamina and cognitive problems that affected his ability to work as a senior insurance underwriting consultant. And remember, carriers are gonna bite their own. Now, in this case, he had received short-term disability benefits but was denied long-term disability benefits. Unum doctors claimed that the record didn't support that he was prevented from doing his sedentary job duties throughout the elimination period. So what's an elimination period? This is another area for traps, if you will, and tools in the carrier's denial toolbox. Many disability policies require continuous absence from work during an elimination period. An elimination period is a period of time in which you have to either be disabled and not working or disabled, or in some cases partially disabled, in some fashion to qualify for your disability benefits.
 
 Nancy Cavey [00:17:46]:
 Now, I gave you 3 examples of different types of elimination policy language, and there's difference not only in language but periods. Elimination periods can be 30 days, 60 days. I've seen them as long as a year. It's really crucial that you're getting out your disability insurance policy or plan and reading it cover to cover, paying attention to pre-existing condition clauses, and to pay attention to elimination periods, paying attention to the definition of disability, occupation, own occupation, any occupation, policy limitations, the need for objective proof, because the foundation, the framework for your claim falls within the applicable terms of your policy or plan. Now, in this case, Mendoza appealed and said, wait, I met the elimination period and I should be paid benefits. Now, fortunately for him, this case was reviewed under the de novo standard of review, which allows a judge to substitute their judgment for that of the carrier. So I like the way this judge went about analyzing the case. And I think this is instructive for you.
 
 Nancy Cavey [00:19:00]:
 The first question the judge said was, "Hey, does Mendoza's cardiac issues prevent him from performing his sedentary job?" Two, did his psychiatric symptoms, insomnia, headaches, prevent him from performing his duties? Three, did the fatigue prevent him from performing his duties? Next, were the cognitive impairments, including brain fog and concentration deficits, disabling under the policy? Now, I liked that because I like the way that the judge took apart each one of the person's— Mendoza's issues, his cardiac issues, psychiatric issues, the manifestation of the symptoms, and then asked how that impacted his ability to perform his own occupation. And then, of course, in doing so, did it in conjunction with the framework of Mendoza's policy. But that wasn't all. The judge went on to review the carrier's medical records and concluded that the cardiac issues were not disabling post-surgery. But he said, look, the success of surgery doesn't necessarily equate with inability to perform the work duties. I think that Mendoza should have ultimately had better proof with residual functional capacity forms an objective measure of his cardiac and pulmonary function to document objectively his restrictions and limitations. Secondly, the judge looked at the records and said, look, the psychiatric symptoms, the insomnia and headaches, lacked sufficient evidence to prove that they prevented work performance. Now, I know that those are conditions that are subjective in nature, but again, I would have had a headache log documenting the nature, intensity, frequency, duration of the headaches.
 
 Nancy Cavey [00:20:50]:
 I would have had potentially his physicians address these particular issues. Now, his physicians may not have been willing to do that, and I understand that. If they had been, I would have had them address the residual functional capacity in terms of forms and potentially reports rebutting the nature of the conclusions made by the physicians. And then the judge looked at his complaints of fatigue and then measured those complaints against the medical records and his forms and his personal statements. And the judge found that it was inconsistent. Consistency is really the key. The judge also looked at the cognitive deficits and found that they weren't supported by the neuropsychological testing. Again, this might have been an issue that could have been addressed through a CPET exam, which is a highly structured exam.
 
 Nancy Cavey [00:21:48]:
 It is expensive. That would address the fatigue and the fatigue's impact on his cognitive functioning, because many times I will see the CPET keyed to a neurocognitive test. The judge rejected Mendoza's personal statement, saying, look, it's not a substitute for medical proof. Now, while I liked the way that the judge went about analyzing the case, asking questions, I certainly didn't necessarily like the way the judge analyzed the medical records and the conclusion that he reached. But I want you to understand that this case gives you a framework for understanding the analysis that carriers will go through. Sometimes maybe the court should do, but that how the medical records and lack of objective medical proof of restrictions and limitations can be fatal to a claim. Obviously, at the end of the day, the judge upheld the denial of benefits. The key takeaway: obtaining necessary Medical proof can be challenging, especially if the providers are unwilling to cooperate.
 
 Nancy Cavey [00:23:02]:
 But if that's happening, then there are ways around it. They may not be cheap, but that could be getting an independent medical opinion. It could be getting objective evidence of limitations, such as a functional capacity evaluation, a CPET exam, neuropsychological testing. And really, it— I think it's the objective documentation of the restrictions, limitations, and ongoing impairments, as those terms are defined by the policy or plan, is really the key to winning a Long COVID or risk of disability case. So that wraps up 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, and share it with your friends and family. Join us next week for another insightful episode of Winning isn't easy. Thanks for listening.