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The importance of documenting functional limitations for long-term disability insurance and Social Security Disability

Functional limitations refer to the severity of loss of physical and cognitive abilities to perform work activities as well as activities of daily life.

In an important sense, functional limitations are more important than diagnosis in the disability claims process. In other words, a person may have a documented diagnosis of ME/CFS, FM, or chronic Lyme, but without the required level of functional limitations he or she will be considered still able to work, and therefore not qualified for disability.

Both Social Security and long-term disability companies have increased restrictions on types of evidence they will accept to validate functional limitations. Formerly, both Social Security and insurance companies would permit functionality to be documented under two required criteria: sustainability and predictability. If these two criteria were documented with a doctor's statement, then the stated lack of functionality would likely be accepted.

Now, Social Security and LTD companies want more objective evidence of loss of functionality—the older standard of proof is no longer sufficient.

Attorneys Rafik and Sullivan find that certain functional capacity tests are helpful in providing such objective evidence—especially during LTD internal appeals. (An internal appeal occurs when a person has been turned down for LTD and utilizes the insurance company appeals process—before having to institute court action.) Ms. Rafik mentioned she has found that Spaulding Hospital provides a type of test that seems to be helpful in showing lack of functionality in ME/CFS and FM cases. These tests cost $500. Ms. Sullivan stated that she had not found neuropsychological tests particularly helpful.

She stressed the importance of maintaining a continuing relationship with the doctors who document your disability as well as building a continuing documentary record of the severity and chronicity of your illness and loss of function.

Both Social Security and LTD insurance companies conduct ongoing reviews of your disability benefits. You must have continuing, periodic, and up-to-date medical documentation of your illness, treatments, and functionality with which to respond to such reviews. Unfortunately, many patients with these illnesses find many treatments to be ineffective and therefore go to their doctors at less frequent intervals, sometimes stopping for long periods. Patients on disability cannot afford to do this. It is very critical to maintain a continuing documentary record—especially doctor's office notes verifying symptoms and objective illness signs. Also, records of all laboratory and other tests should that verify or indicate the illness should be made a part of the continuing record. When periodic reviews occur patients should make sure these documentary records are submitted.

Whenever discussing continuing medical care for ME/CFS and FM patients, it is important to keep in mind another reason for not staying away from the doctor when experiencing a new or changed symptom. Many patients consider such symptoms just another of the many symptoms of their illness. However, new or changed symptoms may not be a fluctuation of their illness; ME/CFS and FM patients are not immune from developing other illnesses, some of which may be serious. As we know, many serious illnesses can be controlled or cured if caught early enough. Don't avoid going to the doctor and later regretting it.