Disability Insurance Carrier’s Position Papers on Tourette Syndrome Claims
Many disability carriers have internal policy statements that guide the claims adjuster, physician and vocational evaluator on how to evaluate a TS claim. These policy statements ignore current research that points to abnormalities in the basal ganglia, frontal lobes and cortex of the brain, and the circuits that interconnect these regions and the neurotransmitters, like dopamine and serotonin, which are responsible for communication among nerve cells. Carriers will try to apply a subjective medical condition limitation to TS claims and deny the claim after the payment of two years of benefits.
Worse yet, many disability policies limit the payment of conditions listed under the Diagnostic and Statistical Manual 5, known as the DMS, to just two years by applying the mental nervous limitation clause. They ignore the science and the organic nature of Tourette’s by purposefully creating a policy exception that should be challenged.
As, a result, disability insurance carriers are denying TS disability claims they once accepted.
The Evaluation Process Used by Disability Insurance Carriers in Every Tourette Syndrome Claim
Step 1: Is Your Tourette Syndrome A Pre-existing Condition?
Tourette’s syndrome is typically noticed first in childhood and most people with the condition experience their worst tic symptoms in their early teens, with improvement into the late teens and continuing into adulthood.
Symptoms can include physical movements like jerking, foot stamping, kicking, and facial movement and can be accompanied by grunts, coughs, barks or shouts. More serious Tourette’s tics can include jumping, touching, smelling, kissing, twirling, biting and other movements that can endanger the sufferer’s wellbeing or that of others. Neuroleptic are often prescribed for tic suppression.
If you have TS and can no longer work, it is crucial that you first consider the disability carrier’s first line of defense. If your policy just became effective and you have gotten treatment for TS or a psychiatric condition during the look back period before the policy became effective, your claim will be denied under the pre-existing condition clause. It is crucial that you don’t pick the wrong date to stop working and file for your benefits if the pre-existing condition clause will result in a denial of your claim.
Step 2: Why Are You Disabled Now?
The carrier will argue that you have had TS for years and have not able to work. As a result, you will have to overcome the carrier’s argument that you have been working with these problems for years and nothing has changed. It is crucial that your medical records develop the progression of your symptoms and that you and/or your employer document how your symptoms have impacted your ability to do your occupation.
Step 3 Your Symptoms are Varied and Intermittent
The disability carrier will argue that your symptoms are varied and intermittent and don’t interfere with your ability to function in the workplace. They will ignore any physical conditions you might have as a result of TS, like a neck condition.
Step 4 Your Complaints are Subjective and/or Psychiatrically Based
Your complaints are just subjective complaints or are psychiatrically based. They will argue both sides of this coin. On the one hand, they will argue that you don’t have any objective evidence that supports your complaints or if you do, your complaints are psychiatrically based so benefits are limited to just two years.
Step 5 No Objective basis of the TS Diagnosis, Restrictions and Limitations
Carriers have another collection of reasons to deny claims which call the three-pack defense. They will say:
(1) There is no objective basis of the diagnosis be it TS or a psychiatric condition like OCD.
(2) There is no objective basis for the restrictions and limitations assigned by your physician,
(3) There is no causal relationship between your TS and/or your restrictions and limitations and your inability to perform your own or any occupation.
How Do I Get the Disability Insurance Benefits I Deserve If I Suffer From Tourette Syndrome?
TS can interfere with your daily activities and your ability to work. If you can no longer work or your doctor has told you to apply for disability, you should do the following before you apply for benefits:
1 – Obtain a copy of your disability policy and see how your policy defines “disability”, “occupation”, “mental nervous conditions,” and “self-reported conditions.” You’ll need to understand what you have to prove and whether there are any limitations in your coverage.
Some policies consider TS to be a subjective condition and/or mental nervous condition and limit benefits to just 2 years. You need to know about any applicable policy limits before you apply for benefits.
2 – Obtain a copy of your medical records and review those records to see if there is any objective basis for your diagnosis, what your records say about your report of symptoms and your restrictions and limitations. One of the most common reasons for denial is the claim there is “no objective evidence to support your subjective complaints.”
Your physician might have noted that you were doing better or had fewer problems functioning. These entries must be addressed before your application is filed or during the appeal process if your claim has been denied.
The disability carrier will often make a leap of logic and conclude that the policy holder is either exaggerating or faking their symptoms. You need to know what proof is necessary to meet the disability policy definition of disability.
3 – Obtain a copy of your personnel file to see whether your TS has affected your performance.
4 – Obtain a copy of your job description and create your own description of your physical and cognitive duties with an explanation of how your symptoms impact your ability to do your occupation. Don’t forget to explain what activities increase your symptoms!
5 – Provide your doctor with the occupational description. Ask your doctor to prepare a report that explains the objective basis for your diagnosis, the objective basis of your restrictions and limitations and the objective reasons you can’t perform some or all the material and substantial duties of your occupation. If your physician won’t cooperate or doesn’t support your claim, it might be time to find another physician.
6 – Prepare a diary that explains your symptoms and any side effects of medication. Be sure to give examples of how your symptoms interfere with your ability to do things daily.
7 – Hire Nancy Cavey to help you file your initial application. The application process is confusing and designed so that you and your physician make mistakes that can result in a delay or even a denial of your benefits. She will work closely with your neurologist and psychiatrist to make sure your records reflect the progression of the peripheral neuropathy and your symptoms. She will also make sure that all Attending Physician Statement forms are completed correctly by your physician.
She knows how to prepare and file a winning shock and awe disability application that leaves the carrier little reason to question your claim.
8 – Hire Nancy Cavey to appeal a wrongful denial or termination of your disability benefits. Disability carriers are in the business of collecting premiums and not paying disability benefits. As a result, they’ll use any reason to deny your TS claim. The odds are that your chances of getting your benefits on appeal are greater when you are represented by an experienced ERISA/private ID policy disability attorney.
Contact Tourette Syndrome Disability Claim Attorney Nancy L. Cavey Who Can Help You Regardless of Where You Live
TS can make it difficult, if not impossible, to work. You owe it to yourself and your family to get help today! Nancy can review your policy, your medical records, and explain to you what your policy says and how to get your disability benefits. Call today for a free consultation at 727-894-3188.
