Proving a disability claim can be daunting even with a diagnosis

By Tony Poland, LegalMatters Staff • Having a diagnosis in a disability claim does not automatically lead to benefits nor does the lack of one necessarily mean you are not entitled to file a claim, says disability lawyer Leanne Goldstein.

Proving an insurance claim can sometimes be difficult, says Goldstein, founder and senior lawyer at Leanne Goldstein Law Professional Corporation, especially in the absence of a medical diagnosis. She uses long-haul covid as a prime example. 

“Many long-COVID claims are being denied because people cannot prove they had a COVID infection,” Goldstein tells LegalMattersCanada.ca. “The science is still emerging in terms of the connection between the infection and lingering issues as most people recover from a COVID infection within a 10-14 day period. Meanwhile, we have people unable to work due to lingering debilitating symptoms and they have to keep fighting their insurance companies for disability benefits.” 

A medical diagnosis is not a guarantee

Even having a diagnosis is not a guarantee that an insurance claim will be approved, she says. 

“Proof of a positive COVID test does not guarantee claim approval largely because disability is not based solely on a diagnosis. It is based on an assessment of functionality, which essentially means, ‘Does the individual have symptoms that are medically verifiable and do those symptoms prevent them from being able to function in the workplace?’ Ultimately, it all depends upon how symptoms are manifesting and what type of job a person is doing,” says Goldstein. “It is not the diagnosis itself that designates the disability, it is how that diagnosis affects that person and how those symptoms impact their ability to function

“For example, someone suffering from long-haul COVID may be dealing with cognitive fatigue or impairment,” she adds. “If they have a job that requires them to use cognitive skills and concentration, such as data entry or accounting, their ability to work will be impacted by their symptoms.” 

‘That’s not where the inquiry ends’

Goldstein says many believe their diagnosis should be the final determination of entitlement to disability benefits “but that’s not where the inquiry ends.” “Many people are shocked when their claims are denied even though they have been diagnosed with a serious medical condition,” she says.

On the surface, being diagnosed with a condition such as multiple sclerosis (MS) or cancer may seem like reasonable grounds to expect a disability claim to be approved, says Goldstein. 

“There are, however, different forms of MS and cancer and degrees to which people experience symptoms,” she says. “There are people who have MS who continue to work, and that might be because they have a less severe form of MS, they may be in a period of remission or they have not manifested symptoms. Or, it might be a situation where they have symptoms, but the symptoms are not significantly impacting their ability to work.”

Insurers often rely on these variations in medical conditions to support their decisions to deny or terminate claims, Goldstein explains.

Insurance company wants detailed information

“Many people think they can simply send in a letter from their doctor documenting their diagnosis and their claim will be approved,” she says. “In fact, what the insurance companies are looking for is more detailed information and a deeper understanding of the impact of their condition on their functionality.”

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Conversely, when someone does not have a diagnosis, “it doesn’t mean that they should not apply for disability benefits or wait until they have a diagnosis before applying,” Goldstein says. 

“The question is not, ‘Do you have a diagnosis?’ The question is, ‘Do you have symptoms that are preventing you from working?’” she says. “Over the years I have had many clients whose medical issues were in the process of being investigated. They may have received a number of differential diagnoses – a list of possible conditions or diseases – but there is still no definitive diagnosis.

‘May be able to get your claim approved without a diagnosis’

 “Some people will delay applying for disability benefits because they are worried that without a diagnosis, they are not going to get approved. But in appropriate circumstances, if you are able to prove you have a condition that is preventing you from functioning in the workplace, you may be able to get your claim approved even without a diagnosis.” 

When pursuing a disability claim it is essential to ensure you are documenting all medical evidence, Goldstein says. 

“Make sure any kind of report a medical professional is preparing for you is very detailed, explaining the nature of your symptoms and how they are impacting you from a functional perspective,” she says. “Documenting restrictions and limitations is important from a physical standpoint but cognitive and psychological impairments should also be outlined.” 

‘Important to continue with any ongoing treatment’

Whether you have received a diagnosis or not, it is also important to continue with any ongoing treatment since “it will help prove that you’re suffering from symptoms that are functionally disabling,” says Goldstein, adding the required frequency of treatment will often depend on the nature of the medical condition.

“If you are not going for treatment and you are not seeing doctors and specialists, then you are not going to have that medical evidence you need to support your disability claim,” she says.

She emphasizes that this is particularly important with “invisible disabilities” – conditions that cannot be detected on diagnostic imaging or with a blood test and the severity of which cannot be “objectively” verified with testing. 

“Long-haul COVID claims may fall into that category especially if the main complaints include chronic fatigue or psychological and cognitive impairment,” says Goldstein. 

She suggests, rather than accepting a disability benefits claim denial or termination, a person should consult with a disability lawyer to “help them paint a more detailed picture” in order to convince the insurer that their claim should be approved.