If you’re unable to work due to a medical condition, you may be eligible for long term disability benefits from your employer or insurance company. However, getting approved for these benefits is not always easy. You will need to provide convincing evidence that you meet the definition of disability under your policy and that you cannot perform the essential duties of your occupation. One of the most important types of evidence you will need is objective medical evidence.
In this article, we will explain what objective medical evidence is and why it is so important for your disability claim.
What is Objective Medical Evidence, and Why is it Important for a Disability Claim?
Objective medical evidence is the cornerstone of your disability claim, providing the concrete proof needed to establish both the existence and severity of your disability in the eyes of your insurance company. It consists of tangible, measurable data that documents your medical condition. Unlike subjective symptoms, which are based on your personal experience and description of pain, fatigue, or other symptoms, objective evidence can be independently verified and quantified through medical tests and examinations.
For instance, if you’re suffering from a back injury, objective evidence might include MRI or X-ray results that show specific abnormalities or damages. Similarly, if you have a condition like rheumatoid arthritis, blood tests that reveal elevated levels of inflammatory markers are considered objective evidence. These pieces of evidence are crucial because they offer unbiased, concrete proof of your medical condition, free from personal interpretation or bias.
The importance of objective medical evidence in your disability claim cannot be overstated. Insurance companies rely heavily on this evidence to make their determination because it provides a clear, verifiable basis for your claim. Without it, your claim might be viewed skeptically, as insurance companies are wary of claims based solely on subjective symptoms, no matter how genuine your experience may be. In essence, objective evidence acts as the bridge between your personal experience of disability and the stringent requirements of your insurance company for proving that disability.
Furthermore, objective medical evidence plays a vital role in establishing the severity of your condition. It’s not enough to simply prove that you have a medical condition; you must also demonstrate that your condition significantly impairs your ability to work or perform daily activities. Here, objective evidence can quantify the extent of your impairment, offering clear data on limitations, ranges of motion, levels of inflammation, or other markers relevant to your condition.
What Types of Objective Medical Evidence Are Most Effective in Supporting a Disability Claim?
The types of objective medical evidence most effective in supporting a disability claim vary depending on the condition you’re dealing with. However, some forms of evidence are universally recognized for their clarity and ability to substantiate claims.
Here are some of the key types of objective evidence and how they can be particularly persuasive for various conditions:
Imaging Tests
X-rays: X-rays are ideal for conditions involving bone fractures, degenerative bone diseases, or dental issues. They provide clear images of bone integrity and alignment.
MRIs (Magnetic Resonance Imaging): MRIs are extremely useful for a wide range of conditions, including brain and spinal cord injuries, tumors, strokes, and musculoskeletal injuries. MRIs offer detailed images of both bone and soft tissues, making them invaluable for diagnosing conditions that might not be visible on X-rays.
CT Scans (Computed Tomography): A CT Scan is best for detecting bone and joint problems, as well as identifying tumors and monitoring cancer progression. They can also provide detailed images of internal organs, useful in diagnosing conditions like liver diseases or internal injuries.
Ultrasounds: Often used for conditions related to soft tissues, vessels, and organs. They are particularly useful in diagnosing conditions in obstetrics, gynecology, and cardiology.
Lab Results
Blood Tests: Can indicate the presence of inflammation, infection, autoimmune disorders, and conditions like diabetes or thyroid disorders. Specific markers, such as the erythrocyte sedimentation rate (“ESR”) or C-reactive protein (“CRP”), can be crucial for diagnosing autoimmune and inflammatory conditions.
Urine Tests: Useful for diagnosing kidney disease, diabetes, and urinary tract infections.
Genetic Tests: Provide evidence for hereditary conditions, genetic disorders, and predispositions to certain diseases.
Objective Findings from Physical Exams
Neurological Tests: Assess nerve damage and the impact on reflexes, strength, balance, and coordination. These types of tests can include electromyography (EMG) or nerve conduction (NCV) tests. These types of tests are particularly persuasive for claims involving neurological disorders, brain injuries, or spinal cord injuries.
Cardiopulmonary Tests: Including EKGs (electrocardiograms) for heart conditions and pulmonary function tests for lung diseases. These tests offer quantifiable data on the functioning of the heart and lungs. A cardiopulmonary exercise test can also be useful to prove disability due to deficits in cardiovascular and pulmonary function during exercise.
Functional Capacity Evaluations (“FCE”): A functional capacity evaluation can provide an assessment of your ability to perform physical work-related tasks such as sitting, standing, walking, lifting, and typing and can be a powerful tool in demonstrating the functional limitations imposed by your symptoms.
Neuropsychological Evaluations: A neuropsychological evaluation can provide an assessment of your cognitive abilities, including short term and long term memory, executive function, reading speed, processing speed, and concentration and attention. A neuropsychological evaluation can be helpful if your conditions are causing brain fog, short term memory loss, or difficulty making decisions or concentrating.
Specialized Tests
Biopsies: Provide definitive evidence of conditions like cancer or certain types of infections by examining tissue under a microscope.
Endoscopies: Useful for gastrointestinal disorders, allowing direct visualization of the interior of organs.
The persuasiveness of these types of evidence often depends on how directly they can link the symptoms you’re experiencing to a diagnosable medical condition. For example, MRIs and blood tests can offer compelling evidence for conditions like multiple sclerosis or rheumatoid arthritis, respectively, by providing clear, indisputable proof of your condition’s presence and impact on your body.
The most effective objective medical evidence is that which can unequivocally demonstrate the presence of a condition and its impact on your health and functionality. The right combination of tests and findings can significantly strengthen your disability claim by offering clear, concrete proof of your medical condition.
How Do Insurance Companies Evaluate Objective Medical Evidence?
When you submit a disability claim, insurance companies evaluate your objective medical evidence using a set of criteria and processes designed to assess the validity and severity of your medical condition. Understanding these criteria can help you navigate the claims process more effectively and potentially avoid common pitfalls that could lead to denial.
Evaluation Criteria and Processes
Consistency: Insurers first look for consistency in your medical records. Your symptoms, the results of objective tests (like MRIs, X-rays, lab tests), and the diagnoses from your healthcare providers should all align. Discrepancies or inconsistencies can raise doubts about the severity of your condition or even the diagnosis itself.
Relevance: The evidence must be directly relevant to your disability claim. This means that the tests and findings should specifically support the condition you claim is disabling you. For instance, if you’re claiming disability due to a spinal condition, spinal MRIs and related diagnostic tests are crucial.
Recency: Your medical evidence should be recent enough to reflect your current condition. Outdated information might not accurately represent your current health status, leading insurers to question whether your disability persists at the claimed level of severity.
Comprehensiveness: The documentation should be comprehensive, covering not just the diagnosis but also your treatment history, responses to treatments, and any changes in your condition. Partial or incomplete records can weaken your claim.
Specialist Input: Evidence provided by specialists relevant to your condition (e.g., neurologists for neurological conditions, orthopedists for bone-related injuries) is often given more weight than notes from your primary care provider. This specificity adds credibility to your claim.
Common Pitfalls and Reasons for Denial
Insufficient Evidence: A common reason for denial is simply not having enough objective evidence to prove your disability. This could mean not enough tests have been done, or the tests that were done do not conclusively support your claim.
Lack of Specialist Evaluation: If your condition is complex and requires a specialist’s assessment, relying solely on your internist’s notes might not suffice. Insurance companies often look for evaluations from specialists to confirm the diagnosis and severity of conditions.
Outdated Information: Claims can be denied if the most recent evidence doesn’t adequately document your current condition. Regular follow-ups and updated tests are crucial to demonstrate the ongoing impact of your disability.
Subjectivity: While subjective reports from you about your symptoms are important, claims based predominantly on subjective complaints with little objective evidence can be challenged or denied.
Noncompliance with Treatment: If medical records suggest that you have not followed prescribed treatments or failed to attend follow-up appointments, your insurance company might argue that your condition is not as severe as claimed or that you have not taken adequate steps to mitigate it.
To navigate these challenges, ensure your medical records are thorough, up-to-date, and include both objective evidence and specialist evaluations directly relevant to your condition. Being proactive in your treatment and documentation can make a significant difference in the evaluation of your claim.
Can a Disability Claim Be Approved Without Objective Medical Evidence?
Proving a disability primarily through subjective symptoms, such as pain and fatigue, can be challenging. Objective medical evidence is often considered the gold standard by insurance companies for validating the existence and severity of a condition. However, there are circumstances under which your disability claim may still be successful, even in the absence of conventional objective evidence.
Without objective evidence, your insurance company may question the credibility of your symptoms. Since subjective symptoms can’t be measured in the same way as objective indicators, they leave room for skepticism. It’s also hard for insurers to assess the severity of your condition based solely on subjective symptoms. Without objective measures, determining how significantly your condition impacts your ability to work or perform daily activities becomes much more complicated.
However, there are some ways to increase your chances of a successful claim outcome with subjective evidence:
Detailed and Consistent Documentation: Detailed records from your healthcare providers documenting your reported symptoms, their observations, and how these symptoms affect your daily life can strengthen your claim. Consistency over time is key — records showing ongoing complaints and treatments related to your symptoms can support the reality and severity of your condition.
Expert Testimonies: Letters or detailed reports from your treating physicians, especially if they are specialists in the field related to your condition, can carry significant weight. These professionals can provide expert opinions on how your subjective symptoms are consistent with your diagnosis and the expected impact on your functionality.
Evidence of Treatment and Response: Documentation of your treatment efforts, including medications, therapies, and any other interventions, along with your responses to these treatments, can help. This shows that you are actively seeking relief for your symptoms and highlights the impact of your condition despite treatment.
Corroboration of Symptoms: Any form of documentation or testimony that can corroborate your subjective symptoms can be helpful. This might include statements from family, friends, or coworkers who have observed the impact of your condition on your daily life.
Certain conditions, such as chronic pain syndromes, fibromyalgia, mental health disorders, and other conditions where objective evidence is notoriously difficult to obtain, may receive a bit more leniency. In these cases, a comprehensive approach, combining detailed subjective reports with whatever objective evidence is available (even if it’s not directly related to your symptoms), can be effective.
How Can I Ensure My Medical Records Accurately Reflect My Disability?
Ensuring your medical records accurately reflect your disability is crucial for the success of your disability claim. The quality and completeness of your medical documentation can significantly impact the evaluation process by insurance companies.
Here are some strategies to help you work effectively with your healthcare providers and ensure your records are comprehensive:
Be Detailed and Specific: When discussing your symptoms and limitations with your healthcare provider(s), be as detailed and specific as possible. Describe how your condition affects your daily life, including any activities you can no longer perform or perform with difficulty.
Keep a Symptom Diary: Maintaining a diary where you record your symptoms, their frequency, and their impact on your daily activities can be incredibly helpful. Share this diary with your healthcare provider during your appointments and submit it your insurance company as further evidence.
Seek Regular Healthcare Appointments: Regularly visit your healthcare providers to ensure your medical records are up-to-date and reflect the current status of your condition. Consistent medical care also demonstrates the ongoing nature of your disability.
Follow Through on Treatments and Recommendations: Adhering to the treatment plans and recommendations provided by your healthcare professionals is essential. Noncompliance can be interpreted as an indication that your condition may not be as disabling as claimed.
Ensure Objective Tests are Part of Your Record: Work with your healthcare providers to ensure that all relevant tests (imaging, lab tests, etc.) have been performed to objectively document your condition.
Request Copies of Test Results: Make sure you have copies of all test results and that they are included in your medical records.
Consult with an Long Term Disability Attorney: An attorney specializing in long term disability claims can provide valuable advice on how to ensure your medical records effectively support your claim. They can help identify any gaps in your documentation and suggest ways to address them.
By following these tips, you can help ensure your medical records accurately reflect your disability, thereby strengthening your disability claim. Effective documentation is key to demonstrating the reality of your condition and its impact on your life, making it crucial to work closely with your healthcare providers and consider legal advice to navigate the process successfully.
What Should I Do if My Claim is Denied Due to Lack of Objective Medical Evidence?
If your disability claim is denied due to a lack of objective medical evidence, it’s important not to lose hope. Most disability insurance policies grant you the right to appeal a denied claim.
Here are some ways you can navigate the appeals process effectively:
Begin by carefully reviewing the denial letter from the insurance company. This letter should explain why your claim was denied and provide information on the appeals process, including any deadlines.
Gather additional evidence that supports your disability claim. This might involve undergoing further medical tests, obtaining detailed statements from your healthcare providers, or compiling records that were previously overlooked.
Seek expert opinions to bolster your case. Consulting with medical specialists who can provide a more in-depth analysis of your condition may uncover new evidence or provide a stronger endorsement of your disability.
Consult with an long term disability attorney. A lawyer who specializes in disability claims can offer invaluable advice and guidance through the appeals process. They can help you understand the intricacies of your policy, gather the necessary documentation, and represent you in dealings with the insurance company.
File your appeal within the required timeframe. It’s crucial to adhere to the deadlines set by your insurance policy to avoid forfeiting your right to appeal.
By taking these steps, you can improve your chances of overturning a denial and securing the disability benefits you need.
Can Subjective Symptoms Be Combined with Objective Evidence to Strengthen My Claim?
Yes, combining your subjective symptoms with objective evidence can significantly strengthen your short or long term disability claim. Subjective symptoms, such as pain, fatigue, and dizziness, are what you experience personally and report to your healthcare providers. While these symptoms are real and can be debilitating, they can be challenging to quantify or verify independently. This is where objective evidence, like lab tests, imaging results, and physical exam findings, comes into play.
When you combine subjective reports of your symptoms with objective evidence, you create a more comprehensive and convincing picture of your disability. This combination shows not only the medical basis for your symptoms but also illustrates how they affect your daily life and ability to work. It bridges the gap between what you feel and what can be medically proven, offering a fuller understanding of your condition.
This approach can be particularly effective because it addresses both the qualitative and quantitative aspects of your condition. It acknowledges the importance of your personal experience of the condition while grounding your claim in concrete medical facts. By doing so, you enhance the credibility of your claim and increase your chances of a successful outcome.
How Can The Maddox Firm Prove My Short or Long Term Disability Claim?
At The Maddox Firm, we specialize in assisting clients with their short or long term disability claims. We understand how to use objective medical evidence to supplement and substantiate your subjective symptom reports, thereby creating a compelling case that illustrates the full extent of your disability. This evidence-based approach allows us to present a persuasive argument to your insurance company, demonstrating not just the existence of your condition, but its tangible impact on your ability to work and perform daily activities.
Our experienced team is committed to supporting you through every step of your disability claim, leveraging our expertise to help secure the benefits you need and deserve. Here are a few ways we help prove your short or long term disability claim:
We Examine Your Policy and Assess Your Claim: First, we conduct a thorough review of your disability insurance policy to understand the specific coverage and the criteria for qualifying for disability benefits. This initial assessment is crucial as it allows us to tailor our strategy to the unique provisions of your policy, ensuring we address all required aspects effectively.
We Handle All Communications with Your Insurance Company: Navigating communications with insurance companies can be daunting. We take this burden off your shoulders by handling all correspondence with your insurer. This includes submitting the initial claim, responding to requests for additional information, and negotiating with your insurance company on your behalf. Our experience with insurance companies enables us to communicate effectively, advocating for your rights and ensuring your claim is given the fair consideration it deserves.
We Help You Obtain Evidence to Support Your Claim: Obtaining robust objective evidence is key to substantiating your claim. We work closely with you to gather all necessary medical records, including imaging tests (such as X-rays and MRIs), lab results, and detailed reports from your treating physicians. These pieces of objective evidence are critical for corroborating the subjective symptoms you experience, such as pain or fatigue. We also assist in arranging additional objective evaluations if needed, to ensure your medical documentation comprehensively reflects the severity of your condition and its impact on your daily life.
We Handle Appeals and Litigation: Should your claim be denied, The Maddox Firm is prepared to pursue all available avenues to challenge the decision. This includes filing a well-constructed appeal that addresses the reasons for denial, providing additional evidence, and clarifying any misunderstandings or gaps in the initial submission. If necessary, we are ready to take your case to court, advocating on your behalf to secure the benefits you deserve.
A short term disability or long term disability claim can be a complicated process. If you need help during the claims process, with appealing a claim denial, or with litigating a final adverse short term or long term disability decision, The Maddox Firm can help. The experienced team at The Maddox Firm will examine your insurance policy, correspondence from your insurance company, medical records, and any other relevant documentation in order to give you personalized guidance on how we can help you win your short and/or long term disability claim. Our New Jersey and New York long term disability attorneys help clients nationwide.
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