02 Jul Medical Conditions and Plan Limitations, Part 2 – “Objective Medical Evidence”
Some disability insurance policies explicitly require “objective medical evidence” in order to approve a participant’s legitimate claim. Yet even in the absence of any plan language, many disability insurance companies frequently deny legitimate claims for benefits if the severity of your condition can not be “objectively” verified through X-Rays, MRIs, or other medical tests. Whether an objective evidence requirement is even permissible under ERISA when the policy does not refer to any such requirement is a contested area of law and fact intensive.
What “Objective Medical Evidence” Plan Language Looks Like:
Long-Term Disability policy language varies and should be read by an attorney knowledgeable of ERISA LTD claims. However, an example of objective medical evidence is below:
Under the terms of the Plan, an employee is entitled to disability benefits if she suffers from “a medical condition supported by objective medical evidence, which (i) makes a Participant unable to perform any type of work as a result of a physical or mental illness or an accidental injury …”
“Objective medical findings include but are not limited to tests, procedures, or clinical examinations standardly accepted in the practice of medicine, for your disabling conditions.”
What Counts as Objective Medical Evidence If My Condition Involves Self-Reported Symptoms?
Many disability insurance companies look very critically at claims for benefits when the participant is disabled due to Fibromyalgia, Chronic Fatigue Syndrome, Lupus, Chronic Lyme Disease, Degenerative Disc Disease, Chronic Pain, etc. This is partially due to the fact that many of the symptoms of these conditions are “self-reported”, including pain, fatigue, confusion, dizziness, fever, chills, shortness of breath, tenderness, etc. There are physicians and diagnostic tests which can help confirm the severity of these disabling conditions, and updated medical literature can also help. Moreover, standard accepted clinical examinations should constitute Objective Medical Evidence when an illness is defined and diagnosed by self-reported symptoms.
Fibromyalgia deserves special attention because long-term disability insurance companies often invoke a policy’s “objective medical evidence” requirement in order to deny disabled participants claims based on a Fibromyalgia diagnosis. The insurance companies often argue that Fibromyalgia is comprised of self-reported or subjective symptoms and therefore cannot be objectively diagnosed. However, Fibromyalgia can be diagnosed using clinical examinations standardly accepted in the medical field.
It is critical that you review your long term disability policy with an ERISA attorney in order to determine whether it requires that your illness be confirmed by “objective” medical evidence or not, and whether such evidence can be required in your state or federal jurisdiction. It is very common for a lack of “objective medical evidence” to be a reason for your denial, when the disability policy does not contain any such requirement.
If you have any questions about your long-term disability claim, call Claire Bushorn Danzl at The Bushorn Firm today at 513-827-5771.