Traumatic Brain Injuries (“TBI”s) can have devastating and lasting effects on your physical, cognitive, and emotional functioning, affecting your ability to work and perform daily activities. If you’ve experienced a TBI, you may need to file for short or long term disability. Navigating the claims process can be overwhelming, but understanding what you need to prove your TBI disability to your insurance company can significantly increase your chances of a successful claim.
In this article, we will discuss how to get short and long term disability benefits for TBIs and what evidence can help support your claim.
How do I qualify for short or long term disability with a Traumatic Brain Injury (“TBI”)?
Qualifying for short or long term disability with a Traumatic Brain Injury (“TBI”) necessitates demonstrating the severity and frequency of your TBI symptoms, which can encompass a range of disabling physical and cognitive impairments.
Individuals with Traumatic Brain Injuries (“TBIs”) may experience a range of physical symptoms, including persistent headaches or migraines, feelings of dizziness or vertigo, episodes of nausea or vomiting, heightened sensitivity to light or noise (known as photophobia or phonophobia), difficulties with balance or coordination, overwhelming fatigue or lethargy, visual disturbances such as blurred or double vision, disruptions in sleep patterns such as insomnia or hypersomnia, and seizures or convulsions.
TBIs can also manifest through a variety of serious cognitive symptoms, including challenges with memory, inability to concentrate, slowed thinking or processing speed, impaired judgment or decision-making abilities, episodes of confusion or disorientation, deficits in executive functioning such as organization, planning, or problem-solving, difficulties with language such as aphasia or trouble finding words, and shortened attention spans or increased distractibility, often coupled with emotional lability or mood swings.
The severity and combination of TBI symptoms can vary widely depending on the individual and the extent of the brain injury. Additionally, some symptoms may manifest immediately after the injury, while others may develop or worsen over time. If presenting severely enough, any of these symptoms can impede you from performing your material job duties.
As serious as TBIs are, a mere diagnosis is insufficient to get your short or long term disability claim approved. Insurance policies typically require that your TBI symptoms are severe and frequent enough to hinder your capacity to fulfill essential job duties, as outlined in your policy’s definition of disability. This necessitates providing compelling evidence to substantiate your claim and symptoms.
How do I prove the severity of my TBI for my short or long term disability claim?
Obtaining short or long term disability benefits for TBI can be challenging, as insurance companies often deny or terminate claims based on insufficient evidence of disability. To successfully prove your TBI disability claim, you need to provide both medical and vocational evidence that shows how your symptoms affect your ability to perform work-related functions. Below we will discuss the types of evidence you need to support your TBI claim.
Proving Medical Disability Due to TBI
Gathering robust medical evidence is a critical step in demonstrating that your Traumatic Brain Injury (“TBI”) is severe enough to impede your ability to work. Start by collecting comprehensive medical records, including diagnostic tests such as CT scans or MRIs, treatment history, and evaluations from healthcare professionals. These records should not only confirm your diagnosis of TBI but also provide a detailed account of your injury’s severity, progression, and the impact of symptoms on your daily life.
When describing your TBI symptoms, provide specific examples of how they affect your ability to function, both at work and in everyday activities. This might include detailing the frequency and intensity of headaches, the duration and severity of cognitive impairments like memory loss or difficulty concentrating, and any physical limitations such as balance problems or fatigue.
Seek assessments from specialists such as neurologists, neuropsychologists, or rehabilitation experts to obtain objective evaluations of your functional limitations. These assessments should focus on how your TBI symptoms directly impair your ability to work. Be sure to discuss with your healthcare providers the importance of documenting not just your diagnosis, but also the impact of your TBI on your physical and cognitive functions.
Proving Inability to Work Due to TBI
Vocational evidence is essential for demonstrating to your insurance company that your TBI prevents you from working. Begin by obtaining your official job description, and writing a personal statement that thoroughly documents your essential job duties. Make sure to highlight the physical, cognitive, and other demands of your work. This includes tasks such as lifting, standing, operating machinery, focusing for extended periods, multi-tasking, and making decisions that are integral to your role.
Describe any changes in your work performance or ability to perform job tasks since sustaining the TBI. This may include instances where you’ve struggled to meet deadlines, made errors in judgment, or required additional assistance or accommodations to complete tasks. If you’ve had to take time off work or transition to a different role within your company due to your TBI, provide documentation of these changes, along with any performance evaluations or feedback from supervisors.
Obtain statements from your employer and/or coworkers who can attest to the impact of your TBI on your work performance. These statements should provide specific examples of how your symptoms prevent you from fulfilling your job responsibilities, including instances where you’ve had difficulty concentrating, communicating effectively, or managing your workload.
You may also consider obtaining the opinion of a vocational expert to provide additional vocational information in support of your claim. By presenting a comprehensive picture of how your TBI impacts your ability to work in your occupation, you can strengthen your disability claim and increase your chances of securing the benefits you need.
Are there specific medical tests or evaluations that are crucial for supporting my TBI disability claim?
Yes, there are specific medical tests and evaluations that can be crucial for supporting your Traumatic Brain Injury (“TBI”) disability claim. Two important assessments to consider are Functional Capacity Evaluations (“FCE”) and Neuropsychological Evaluations:
Functional Capacity Evaluation (FCE): Functional Capacity Evaluations are comprehensive assessments conducted by trained professionals, such as physical therapists or occupational therapists, to evaluate an your physical abilities. These evaluations typically include a series of tests and tasks designed to measure strength, flexibility, endurance, and functional abilities related to work tasks. For individuals with TBI, an FCE can provide objective data on physical impairments that may affect their ability to perform essential job duties, such as lifting, carrying, standing, or sitting for prolonged periods. The results of an FCE can help demonstrate the functional limitations caused by TBI and provide valuable evidence to support a disability claim.
Neuropsychological Evaluation: Neuropsychological evaluations are conducted by neuropsychologists to assess cognitive functioning and identify deficits resulting from TBIs or other neurological conditions. These evaluations typically involve a battery of standardized tests and measures to assess various cognitive domains, including attention, memory, processing speed, executive functioning, and emotional functioning. Neuropsychological evaluations can provide detailed information about the specific cognitive impairments caused by your TBI and their impact on your daily functioning and work-related tasks. The results of a neuropsychological evaluation can help corroborate subjective reports of cognitive difficulties and support the need for disability benefits.
In addition to FCEs and neuropsychological evaluations, other medical tests and assessments may also be relevant depending on your symptoms and functional limitations. These may include neuroimaging studies (such as CT scans or MRIs) to visualize structural brain abnormalities, neurological examinations to assess motor function and sensory perception, and specialized tests to evaluate specific symptoms (e.g., vestibular testing for balance problems).
When pursuing a TBI disability claim, it’s essential to work closely with healthcare providers who are experienced in evaluating and treating TBI, as they can recommend appropriate assessments and provide documentation to support your claim. Additionally, consulting with an experienced disability attorney can help ensure that you gather the necessary medical evidence and navigate the claims process effectively.
What are common challenges or pitfalls encountered by claimants with TBIs during the disability claims process?
Claimants with Traumatic Brain Injuries (“TBI”) encounter several challenges during the disability claims process, exacerbated by unique aspects of TBI symptoms:
The symptoms of TBIs are generally expected to improve: Your disability insurance company will say that the effects of a TBI are usually expected to improve. If your symptoms are not improving, make sure the lack of improvement is adequately documented. What happens to "the majority of individuals . . . is the weakest possible evidence" of what is happening to you. See Hawkins v. First Union Corp. Long-Term Disability Plan, 326 F.3d 914, 919 (7th Cir 2003) (Posner, J.).
TBIs are often marked by subjective symptoms: Many TBI symptoms, such as fatigue and headache, can be subjective and challenging to quantify. The lack of objective evidence for these symptoms may lead to skepticism from your insurance company. To counteract this, make sure to provide detailed documentation of your symptoms and their impact on your daily life. Seek objective assessments from specialists like neuropsychologists. These can go a long way in substantiating your condition to your insurance company.
Inconsistent Medical Documentation: Incomplete or inconsistent medical records can weaken claims, especially when symptoms don’t follow the typical progression of TBI injuries. Your disability insurance company may mistakenly feel you are taking longer than expected to recover, or that because your symptoms fluctuate between “good” and “bad” days, they are not severe enough to prevent you from working. It’s essential to treat with your providers regularly, creating a paper trail of thorough documentation of your symptoms and treatment history. When attending doctor visits, make sure to note all of your symptoms, even if the purpose of the visit is only to address one of them.
Difficulty Communicating Symptoms: Some people who experience TBI may struggle to articulate their symptoms or lack insight into their impairments, making it challenging to convey the extent of their disability. Seek assistance from caregivers or healthcare providers to help you accurately describe your symptoms. It can also be helpful to maintain a journal to track your day-to-day symptoms and daily difficulties.
Impact on Specific Professions: Even minor cognitive impairment can prevent some claimants from working in certain professions, given the high-level cognitive demands they entail. However, your insurance company may be skeptical. Make sure to highlight the specific job duties your occupation requires that are affected by your cognitive impairments. Provide evidence of your functional limitations that hinder job performance. It can be very helpful to obtain a vocational assessment from an expert to offer your insurance company a complete picture of your occupational duties.
What recourse do I have if my TBI disability claim is denied by my insurance company?
If your Traumatic Brain Injury (“TBI”) short or long term disability claim has been denied, know that you’re not alone in facing this challenging situation. Here are a few steps you can take:
Review the denial letter: It can be disheartening to receive a denial letter, but understanding the reasons behind it is the first step toward addressing the issue. Take your time to carefully examine the letter from your insurance company. Note the specific reasons provided for the denial and any additional documentation they may be requesting to reconsider your claim.
Understand your appeal options: You have the right to challenge the decision and present new evidence or arguments in support of your claim. Familiarize yourself with the appeals process outlined in the denial letter. Pay close attention to any deadlines for submitting your appeal to ensure you don’t miss important timelines. If your policy is governed by ERISA, you likely have 180 days from the date of denial to file your appeal.
Request a copy of your claim file: Requesting a copy of your claim file from the insurance company can provide valuable insight into the decision-making process. This may include medical consultant reports, Independent Medical Examination findings, or other internal notes not disclosed to you before the denial. Reviewing the claim file may reveal errors or discrepancies that influenced the denial. This information can be invaluable as you prepare to appeal the decision.
Seek legal guidance: Navigating a denied disability claim can be overwhelming, but you don’t have to go through it alone. Consider seeking legal guidance from an attorney specializing in disability insurance claims. An experienced long term disability attorney can provide invaluable support and advocacy, helping you understand your rights and navigate the appeals process effectively.
How Can The Maddox Firm Prove My TBI Disability Claim?
The Maddox Firm has helped hundreds of our clients secure their disability benefits, including many who experienced Traumatic Brain Injuries (“TBI”). We understand the challenges you face when needing to secure short or long term disability for a TBI and how to maximize your chances of securing benefits.
Here’s how our expertise can benefit you:
We Examine Your Policy and Assess Your Claim: The Maddox Firm thoroughly examines your policy to identify coverage details, the eligibility criteria you must meet, and any important provisions or exclusions. This allows us to build a personalized strategy for your claim. We ensure that you understand your rights under your policy and how they relate to your TBI disability claim.
We Handle All Communications with Your Insurance Company: Dealing with insurance companies can be daunting. Our team takes the burden off your shoulders by handling all communications with your insurance company on your behalf. The Maddox Firm knows how to effectively communicate with insurance companies to advocate for your rights and push for a favorable outcome.
We Help You Obtain Evidence to Support Your Claim: The Maddox Firm recognizes the importance of gathering compelling evidence to support your TBI disability claim. We assist you in obtaining the necessary medical and vocational documentation, including neuropsychological evaluations, Functional Capacity Evaluations, and vocational assessments. Our goal is to build a strong case that clearly demonstrates the severity of your TBI symptoms and their impact on your ability to work.
We Handle Appeals and Litigation: If your TBI disability claim is denied, The Maddox Firm will represent you through the appeals process and, if necessary, litigation. Our experienced team is skilled in crafting persuasive appeals that address the reasons for your initial denial and present compelling evidence in support of your claim. We’ll guide you through each step of the process, from filing the appeal to representing you in court if litigation becomes necessary.
A Traumatic Brain Injury 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 for your TBI. Our New Jersey and New York long term disability attorneys help clients nationwide.