Back pain has a fundamental impact on the lives of many people throughout the U.S., as well as other countries.  If you have ever experienced the debilitating impact of crippling back pain, it may come as little surprise that back pain is the most prevalent disability worldwide.  Further, nearly half of all Americans report suffering back pain at some time during a typical year.  Back-related pain also is one of the leading causes of missed work and the second leading reason for visits to the doctor behind only upper respiratory infections.  Despite the prevalence and severity of back injuries and conditions, private long-term disability insurance carriers frequently deny disability claims involving back injuries. 

Here we provide an overview of information related to long-term disability insurance claims based on back injuries. 

The basic challenge in bringing disability insurance claims based on back injuries or conditions involves difficulty in proving that a back injury meets the definition of “disability”.  Many debilitating back injuries that cause devastating pain are difficult to establish with indisputable medical evidence, such as diagnostic imaging.  Since pain is subjective in nature, an understanding of the types of serious back injuries that cause disability and the appropriate steps to preserve a long-term disability insurance claim are essential to maximize the probability of a desirable outcome.

There are many types of back conditions that can result in the inability to continue in your occupation or even work in any occupation.  Common disabling back issues include:

Herniated Disc: This medical condition also is referred to as a “slipped disc” or a “ruptured disc”.  When the soft internal cartilage of a disc penetrates through the hard exterior of the disc, penetrating material can protrude into the spinal canal and cause nerve irritation.  This contact with nerves can cause numbness, pain, and tingling that radiates into the extremities.  Sciatica often is caused by this type of disc deterioration, which is characterized as pain that radiates down the sciatic nerve from the lower back into the legs.  Less intense pain can be caused by a condition that is not as severe referred to as a “bulging disc,” which simply causes swelling of the disc.  

Osteoporosis: Severe vertebrae fractures that can be caused by diminished bone density can inflict severe pain and necessitate surgery.  The decreased bone density causes the bones of the spine to be brittle and susceptible to fractures.

Degenerative Disc Disease (DDD): This spine disorder is characterized by deterioration of the discs made of cartilage that act as cushions between the vertebrae.  If the discs are healthy, they have the ability to absorb considerable shock, but diseased discs become rigid and thin.  This condition typically causes chronic pain of the lower back that radiates into the hips, legs and buttocks.  Surgery might be needed to insert an artificial disc or to relieve pain with disc fusion.

Spinal Stenosis: This medical condition occurs when the spinal canal narrows in the lumbar or cervical spine.  When this narrowing occurs the result can be compression of the root portion of the nerve.  If the narrowing of the spinal canal occurs in the spinal cord, the condition can be life-threatening.

These are just a few serious examples of back injuries that can justify long-term disability insurance benefits.  While any of these spinal conditions and others can result in functional impairment that merits long-term disability insurance benefits, this determination will depend on the degree of functional limitation of an individual.  These limitations can vary widely between disability claimants despite similar diagnostic imaging and/or diagnoses.

Many back-related disabilities must be established without compelling objective medical evidence.  Strong claims might be approved based on the medical diagnosis of severe degenerative disc disease along with impaired functional capacity, which reveals a significant limitation on range of motion.  The challenge is that in most cases the objective evidence could go either way depending on the individual.  It is not uncommon that one person is able to work while the other would be incapacitated based on the same medical evidence.  In these borderline cases, claimants need to build compelling appeals of their denials.  The following steps can improve your ability to present a compelling case on appeal.

Create a Strong Medical Record: Prompt medical attention is essential, which includes attending scheduled appointments with physicians and specialists.  Treating doctors and specialists generally will order diagnostic imaging, such as CT scans, X-rays, and MRIs.  When claimants fail to comply with basic follow-up for diagnostic imaging, treatment, and rehabilitation, this will be used by the insurance carrier to deny a long-term disability insurance claim.  Claimants should make sure to follow all of the following common instructions.

  • Fill and take prescribed medication
  • Get rest
  • Attend physical therapy appointments
  • Show up for doctor’s appointments

While a painful back problem is a physical condition, the limitations and intense pain often result in psychological symptoms like depression and stress.  Claimants  you also should seek the care of a mental health professional and disclose these issues.

Obtain other evidence and opinions: Because a disability insurance claim essentially turns on the impact of a back injury on your functional capacity, information provided by those who know you best also can be effective evidence.  Family, friends, co-workers, and colleagues see and interact with you on a regular basis, so they can provide a compelling picture of your physical limitations and the mental health-related impact of your spinal problem.

Ensure Documentation of Physical/Mental Limitations: Claimants should request that their treating doctor and/or specialist evaluate their functional limitations with a Residual Functions Capacity form or a narrative report.  Limitations involving sitting, stooping, carrying, bending, walking and standing should be noted on the report.  Additionally, secondary limitations should be reported, such as difficulty concentrating or fatigue.  These secondary symptoms are especially important if your doctor expects that you might need to miss work often or that you will need periodic rest periods during the day.  If your doctor puts forth reasonable effort in documenting these limitations, these details can strengthen a long-term disability insurance claim.

Seek Experienced Long-Term Disability Insurance Claims Attorney: While private carriers often are cooperative in providing temporary benefits under a long-term disability insurance policy, this initial cooperation often disappears before an award of long-term disability insurance benefits.  Whether you are initially denied temporary benefits or you suddenly have your benefits terminated, an experienced disability insurance claims attorney can guide you through the minefield of insurance company hurdles and traps.  Our law firm protects the contractual and legal rights of our clients while pursuing the full measure of benefits under an insurance policy.

You can reach Miami Insurance Claims Lawyer J.P. Gonzalez-Sirgo by dialing his direct number at (786) 272-5841, calling the main office at (305) 461-1095, or Toll Free at 1 (866) 71-CLAIM or email Attorney Gonzalez-Sirgo directly at [email protected].

J.P. Gonzalez-Sirgo
J.P. Gonzalez-Sirgo, P.A.
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