Why is a diagnosis not enough?

Embarking on the long term disability claims process with your group insurance company can be an arduous and emotionally trying process. Endless requests for medical documentation and updated information can be difficult to deal with when you are trying to cope with physical or psychological impairments.

Even after you have provided all the necessary documentation that the insurance company has requested, they may still deny your claim on the basis that there is insufficient medical information to support your disability. A denial of this nature can be extremely confusing, when a family physician or specialist has provided a letter to the insurer in which a clear diagnosis of one or more medical conditions is indicated.

In some cases however, a diagnosis alone may not be sufficient to determine whether an individual meets the test for disability contained in the applicable insurance policy or plan. Given the idiosyncratic nature of the human body, different individuals may respond differently to the same disease process. The nature and severity of the symptoms of the illness may differ for a multitude of reasons. There may be pre-existing medical issues that predispose an individual to more severe symptoms or psychological issues that exacerbate a medical condition.

So while two people may be diagnosed with the same illness, one may respond well to treatment, the other may not. One may have mild symptoms and be able to function in the workplace, the other may not. It is crucial therefore to ensure that you accurately describe for the physician or specialist who may be preparing your disability claim forms the nature and extent of your symptoms and how they impair your ability to function in the workforce and at home.

In an Attending Physician's Statement (the document that an insurance company usually requires from your physician and/or specialist to commence your application for benefits) and the medical reports that are prepared pursuant to a request for further information from the insurance company, it is important for your physicians and specialists to consider all of your symptoms, physical and psychological, and more importantly, how these symptoms affect your ability to function. Functional ability is an essential component in analysing whether an individual meets the test for disability contained in the applicable insurance policy or plan.

It is, however, important to bear in mind that every disability insurance policy is unique and an assessment of disability must take place in the context of the definition contained within the applicable insurance policy or plan. Most disability insurance policies contain more than one definition of disability that an applicant must meet before they can be entitled to ongoing benefits.

The foregoing does not constitute legal advice. If you have unsuccessfully appealed your claim for disability benefits or your benefits have been terminated at the "change of definition", you may want to consider whether you require legal assistance to further advance your claim.