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Legal: Disability Claims – Can Pain Be The Main Limiting Factor?

June 5, 2007

I found this legal case to be interesting to EDS patients. First some
background – if you have an employer paid disability plan, the plan is
governed by US pension laws called ERISA. Those laws give the
disability plan a lot of discretion – they basically need only to show
that their decision to deny you befits is reasonable. And you cannot
get punitive damages so even if they wrongly deny you benefits, they
lose nothing beyond your actual benefits. As you can see there
are advantages to automatically denying employees long term disability
and the forcing employees to fight it out in court.

In this
Northern District California case, a employee had carpal tunnel
syndrome. Her disability was not one that showed actual damage –
basically, the doctors, realizing that pain was her main limitation,
advised her to restrict her activities. The disability company denied
her benefits because, among other reasons, there was no evidence of
damage and pain was her main limiting factor.

This happens a lot
with people with EDS – we dislocate and subluxe but often there is no
damage evident. But because of our hypermobility, we have a lot of
pain.

There
is no factual dispute that Wood was diagnosed with carpal tunnel
syndrome in 1999,that she underwent spinal surgery in 2000, and that
she continues to suffer pain and numbness in her hands to this day. The
reports of all of the physicians who actually examined or treated her
support her disability claim, with the exception of the report of
Dr.Teitel, who examined Wood at the Plan’s request when she sought
first phase LTD benefits. Even Dr. Teitel did not find that Wood was malingering or exaggerating her symptoms.
He
stated that the recommendations of Wood’s treating physicians
were’appropriate in terms of limiting her discomfort but not an
absolute limitation because it is not clear that these activities will
produce damage to tendons, joints, muscle or nerve.’ The policy’s
definitions do not, however, exclude disability on the basis of pain
and do not require that activities cause damage to tendons, joints,
muscle or nerve before they qualify as limitations.

Dr.
Ito, the Plan’s consulting doctor who did not examine Wood, did not
dispute Wood’s diagnoses or the findings of pain, weakness and numbness
documented by numerous doctors over time. However, Dr.
Ito apparently discounted Wood’s pain limitations on the basis that
they were not supported by objective testing. The policy’s definitions
do not require the type of direct test support that Dr. Ito apparently
required to support Wood’s pain complaints and other limitations.”

Note
the key here is ‘what does the policy say.’ I would think that if you
have a medical report that shows exactly how much hypermobility you
have (supported by an actual test – ‘look I can bend her elbows
backwards, isn’t that freaky?”) you’d have your objective medical
evidence. That coupled with consistent MD reports about pain seems (to
me) to be a strong claim. But what do I know, eh?

Complete article here:
(also this is not legal advice – check with a lawyer if you need advice on your disability claim)

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