Problems in Subjective Complaint Claims

Where an individual suffers from a condition that is not easily diagnosed by objective testing, they often face great difficulty in having the insurance company accept liability for the payment of disability benefits.  Some of the more common conditions that face this kind of resistance by the insurance company include claims related to fibromyalgia, chronic fatigue syndrome, depression, back injuries and even cases of rheumatoid arthritis.  Even in cases where herniated discs are apparent from an MRI, insurers will often challenge the claim for disability, arguing that there is no impingement upon nerves or that the condition is simply degenerative.

The key to succeeding with claims based upon subjective complaints is in having the treating physician strongly advocate for the claimant, providing well documented clinical findings, restrictions and limitations.  Where the treating physician lacks zeal for the claimant, the claim is often doomed to be denied.  It is therefore very important that a claimant ensure that they work closely with his or her doctor when advancing such claims.

While some disability policies contain language requiring objective medical evidence in support of a claim, the majority of policies do not contain such provisions.  Nonetheless, many insurers inject the requirement into the claim process unilaterally, without consideration for the nature of the claimant's condition or regard for the fact that such a requirement will be impossible for the claimant to satisfy.  Symptoms such as fatigue, pain, lack of energy, focus and concentration are difficult to demonstrate objectively.  The insurance company's medical personnel will often have the opinion that the claimant's restrictions and limitations are not supported by objective medical evidence.

Nevertheless, Courts have required insurers to take into consideration a claimant's subjective complaints when deciding upon the validity of the claim, if the claimant's credibility is not challenged.