By Matthew DeGioia, (301) 563-6685
Has your insurance company denied your claim for Long Term Disability insurance benefits?
Before filing your appeal, you may want to consider undergoing a Functional Capacity Evaluation (FCE). An FCE is an extensive physical examination that determines a person’s baseline functional capabilities and assesses a person’s ability to return to work.
What to Expect
The purpose of the FCE is to allow a patient to simulate everyday workplace tasks on a sustained basis so that the evaluator can quantify objective findings of the patient’s exertional limitations. An FCE typically takes three to four hours total. In some cases, a patient may request evaluations to be performed on back-to-back days to assess baseline functional capabilities over multiple days. In particular, the FCE tests the patient’s ability to sit for extended periods, stand for extended periods, perform sustained reaching, balance, perform sustained bending, squatting, and crawling. The FCE also can test a patient’s hand dexterity, including a patient’s ability to work with tools and manipulate smaller work-related items in a competitive workplace setting. Throughout the FCE, the evaluator, typically a licensed physical therapist, takes note of how the patient responds to the different exercises, including every instance the patient needs to stop performing an activity due to pain or other symptoms.
Before the FCE, the evaluator will review any relevant medical and vocational information for context of the patient’s problem areas. During the FCE, the evaluator typically begins by taking a history of the patient and summarizing his or her chronic medical problems, any results of diagnostic testing, and procedures performed relevant to the patient’s functioning. The evaluator also usually asks the patient to describe their chief complaints and the activities they perform on a typical day. The evaluator then conducts a preliminary musculoskeletal evaluation, assessing the patient’s posture and gait and range of motion in their spine and joints. The evaluator also performs manual muscle testing from head to toe, neurological deep tendon reflex testing and sensation testing, and soft tissue palpation testing.
Upon completing the FCE, the evaluator will generally provide a summary of the patient’s functional abilities, including the extent a patient can perform the aforementioned exertional functions, the maximum weight the patient can lift and carry, as well as the frequency with which the patient can carry different ranges of weight. The evaluator will then conclude the FCE report by providing a professional opinion of the patient’s ability to perform work. The FCE will also typically report on any symptom magnification – that is, instances where a patient greatly exaggerates their symptoms to document a higher level of impairment than is accurate. To counteract such false reporting, the evaluator will consider how the claimant reports their pain symptoms and their medical and occupational history, their reported goals, the consistency in the patient’s answers and behaviors, and how they react to particular exercises.
How an FCE Can Support a Long Term Disability Claim
FCEs are particularly useful in supporting Long Term Disability appeals because they can assist a decision-maker in determining a claimant’s capability to perform their former job or any job. Long Term Disability benefits are payable if a claimant meets the Long Term Disability insurance policy’s definition of disability and if the claimant’s medical condition does not fall within one of the limitations or exclusions of the policy. The insurance policy’s definition of disability often directs benefits to be paid if a claimant is medically unable to perform the material duties of his or her occupation or any occupation for which the person may reasonably become qualified based on education, training, or experience. The extensive nature of the testing, coupled with the checks as mentioned above against symptom magnification, have led courts to conclude that an FCE “is generally a reliable and objective method of gauging the extent one can complete work-related tasks,” Shaw v. AT & T Umbrella Ben. Plan No. 1, 795 F.3d 538, 548 (6th Cir. 2015) (citing Caesar v. Hartford Life & Accident Ins. Co., 464 Fed.Appx. 431, 435 (6th Cir. 2012) (internal quotation marks omitted)).
Moreover, FCEs can help assist Long Term Disability claimants who are subject to limitations clauses. Under many Long Term Disability policies, a claimant can be limited to receiving only 24 months of disability benefits if their disability is caused or contributed by a mental disorder or other conditions with subjective symptomatology, such as chronic fatigue conditions, chronic pain conditions, and environmental allergies. To overcome the limitation, it may be helpful for a claimant to undergo an FCE to document the extent to which the person is physically precluded from performing essential work tasks and provide objective findings to corroborate a patient’s ongoing complaints of pain or fatigue.
Finally, FCEs can be helpful for Long Term Disability claimants seeking support from their treating physicians for their claims. Some doctors are hesitant to opine a patient’s medical inability to work before evaluating them for their remaining functional capacity. By undergoing an FCE, you can give your doctor an evaluation with objective clinical findings upon which he or she can base their medical opinion regarding your work capability.
It is essential to consider the complexity of the Long Term Disability claims process before determining whether to undergo an FCE. Please be careful and consider contacting me if you have questions about your Long Term Disability Insurance claim. Please feel free to call me at 301.563.6685 for a free consultation regarding your claim.
About Andalman & Flynn, P.C.: Founded in 1998 in downtown Silver Spring, Maryland, Andalman & Flynn has forged a distinguished reputation for legal excellence. The firm represents individuals seeking disability benefits throughout the country and practices family law throughout Maryland and the District of Columbia. The firm focuses on cases that impact the rights of everyone, and are there for clients when responsive legal help is most critical. The firm has provided legal analysis on national and local television and radio, and their attorneys often testify before legislative bodies and are routinely invited to contribute to prominent legal publications. For more information about Andalman & Flynn, please visit the website at andalmanflynn.com or call 301.563.6685