Long-term disability benefits for chronic conditions can provide important financial support when a chronic illness prevents you from working. Living with a chronic condition means managing symptoms that can fluctuate over time, with some periods being easier to manage than others. Changes in symptoms, medications, medical appointments and sick days can all affect your ability to work.
If you live with an episodic or fluctuating condition, it is important to understand how to properly document changes in your symptoms and functional abilities. Conditions such as multiple sclerosis, autoimmune diseases, fibromyalgia and depression can be well-managed for periods of time before symptoms worsen. If you need to make an LTD claim for a chronic condition, strong medical documentation can help demonstrate how your condition affects your ability to work.
TL;DR:
Long-term disability claims involving chronic conditions are frequently denied because symptoms often fluctuate rather than remain constant. Proper medical documentation, consistent treatment, and detailed records of how your condition affects your ability to work can significantly strengthen your disability claim and improve your chances of approval.
Overview
People living with chronic conditions may experience periods when their symptoms are manageable and other periods when their condition becomes significantly worse. Long-term disability benefits for chronic conditions may be available when symptoms prevent you from performing the essential duties of your job, even if your condition is episodic or fluctuates over time.
Strong medical documentation is critical. Keep records of changes in your symptoms, medical appointments, medications, treatments and functional limitations. Most importantly, your medical records should explain how your condition affects your ability to work, not simply identify your diagnosis.
If your LTD claim has been denied because your insurer does not believe your chronic or episodic condition is disabling, a disability lawyer can review your policy, medical evidence and the reasons for the denial.
What are episodic and fluctuating disabilities?
 Episodic and fluctuating disabilities are conditions in which symptoms can vary significantly over time, including periods of relative stability followed by periods of increased or disabling symptoms.
Conditions like:
- multiple sclerosis
- autoimmune diseases
- fibromyalgia
- depression and other mental health conditions
- migraine disorders
- Crohn’s disease
- Rheumatoid arthritis
fall under the chronic condition umbrella. A diagnosis of a chronic condition means there is no permanent cure for the diagnosis. Rather, people are given medical intervention to manage the condition.
A chronic condition does not necessarily mean that a person is continuously unable to work. Many people successfully manage their symptoms for years while continuing to work.
However, symptoms can change. A person who has been able to work despite a chronic condition may experience significant deterioration that makes continuing to work impossible or substantially more difficult.
This is an important consideration when applying for long-term disability benefits for chronic conditions.
Can you qualify for long term disability benefits with an episodic disability?
Yes. An episodic or fluctuating condition can qualify for long-term disability benefits if the symptoms and resulting functional limitations prevent you from being able to do your job.Â
The fact that a condition is intermittent does not automatically mean that it is not disabling. Due to the nature of the condition, a claimant may have a diagnosis that is well-managed for years without needing to go off work.
For example, many people diagnosed with multiple sclerosis have medically managed the diagnosis and are able to perform their daily functions. However, physical trauma (like a motor vehicle accident) can trigger the diagnosis to become unstable.Â
When an episodic condition becomes unstable after a triggering event, insurance companies struggle to understand why the condition is now preventing a person from working.
The relevant question for an LTD claim is not simply whether the claimant meets the policy definition of total disability, or not simply whether the person has a chronic diagnosis. The important issue is whether the person’s current symptoms and functional limitations prevent them from performing their occupation, or another occupation if required by the terms of the policy, and claims can be denied if that definition is not met. This does not mean the person must be bedridden or helpless; it turns on whether they can work reliably in the occupation defined by the policy.
This distinction can be particularly important when an insurer is assessing an LTD claim involving an episodic or fluctuating condition.
Why are LTD claims for chronic conditions sometimes denied?
LTD claims involving chronic or episodic conditions may be denied when an insurer focuses on the diagnosis or periods of stability rather than the claimant’s current functional limitations. Denials also commonly happen after the two-year mark, when many policies change disability definitions and insurers often deny claims by changing the definition of what it means to be be able to work.
Someone may have successfully managed a chronic condition for years without taking significant time away from work. Their medical records may therefore show a long history of working despite the diagnosis.
When symptoms suddenly become more severe, an insurer may question why the condition is now preventing the person from working. The lack of understanding creates a disconnect and causes claims to be wrongfully denied.
The key issue is the person’s current functional capacity, especially because LTD claims often change from an own occupation test to an any occupation test after two years, which can trigger denial if the insurer says the person can do other work.
That is why medical documentation should clearly explain what has changed, what symptoms are now present and how those symptoms affect the person’s ability to perform their work.
How should you document an episodic or fluctuating disability?
The best way to document an episodic or fluctuating disability is to create a consistent record of symptoms, treatment and functional limitations over time.
If you’ve noticed a negative change in your chronic diagnosis, consider keeping a detailed record that includes:
1. Document changes in your symptoms
Keep a daily log and record:
- The symptoms you experience
- The severity and duration of the symptoms
- Frequency of symptoms
- Any significant change from your usual baseline
- Activities that worsen or trigger symptoms
- How your symptoms affect your ability to function
This symptom log can show that your condition is not static and may be useful to the treating physician.
2. Log your doctor’s appointments
Track your medical appointments including:
- The date of appointment
- The reason for the appointment
- Changes in symptoms
- TestsÂ
- Treatment recommendations
- Referral to specialists
- Any restriction or limitation identified by your doctor
3. Maintain list of your current medications
Keep a list of your current medications and document changes including:
- New medications
- Increased or decreased dosages
- Discontinued medications
- Side effects
- Changes in treatment effectiveness
These changes provide important evidence of the change in the severity or management of your condition.
4. Document functional limitations
Document what you can and cannot do because of your symptoms. Focusing only on the diagnosis is not enough.
Depending on your condition and occupation, this could include difficulty with:
- Concentration
- Memory
- Walking
- Lifting
- Sitting or standing for extended periods
- Typing of using a computer
- Working predictable hours
- Meeting deadlines
- Performing repetitive tasks
- Managing stress
Your insurer needs to understand how your symptoms limit your ability to do your job.
How can you strengthen a long-term disability claim for a chronic condition?
This is usually straightforward; ensure you have your doctor’s support. Having a doctor who can vouch for your inability to return to work strengthens your claim. Working closely with your doctor to elaborate closely on how your diagnosis impacts your functionality can help your insurer understand how your current symptoms negatively impact your ability to work.
If the insurer relies on pre-existing condition clauses to dispute whether you are eligible for benefits, ask your doctor to address those issues directly in the medical records.
The strongest LTD claims generally include medical evidence that connects the claimant’s symptoms and functional limitations to their inability to work.
Ask your treating physician to clearly document:
- Your diagnosis and relevant medical history
- The symptoms you are currently experiencing
- How your symptoms have changed
- Your functional limitations
- How those limitations affect your ability to perform your job duties
- Any treatment you are receiving
- Your response to treatment
Focus on function, not just the diagnosis. This distinction is especially important for long term disability benefits for chronic conditions.  A chronic diagnosis may not change for years, but a person’s ability to function may change significantly.
Your medical documentation should tell the story of what changed and why you can no longer work.
Key takeaways
- Chronic conditions can fluctuate significantly over time and may include periods of stability and periods of serious impairment.
- An episodic or fluctuating disability can still support a long-term disability claim.
- A diagnosis alone is usually not enough to establish entitlement to disability benefits. Medical evidence should explain your functional limitations and how they affect your ability to work.
- Keep detailed records of changes in symptoms, medical appointments, medications and treatments.
- Your doctor should clearly document how your condition affects your ability to perform your job duties.
- A triggering event can sometimes cause a previously managed chronic condition to become significantly worse.
- If your LTD claim is denied, the insurer’s reasons for denial should be carefully reviewed before deciding how to respond.
What if your long-term disability claim for chronic condition is denied?
If your LTD claim for a chronic, episodic or fluctuating condition is denied, you should carefully review the insurer’s reasons for denial and the evidence supporting its decision.
Do not assume that an insurer’s decision is correct simply because your condition is chronic or because you previously continued working with the diagnosis.
Contact the disability legal team at Whitten & Lublin. Getting the right legal representation can help navigate you through this complicated process. An experienced disability lawyer can review your disability policy, challenge the wrongful denial on your behalf and put the important medical documentation in the spotlight.
The disability team at Whitten & Lublin offers free consultations for denied short- and long-term disability claims. Contact us online or call 416 640 2667.
Frequently Asked Questions
Can a chronic illness qualify for long-term disability benefits?
Yes. A chronic illness can qualify for long-term disability benefits if the condition causes symptoms or functional limitations that meet the definition of disability under the applicable insurance policy.
Can you get LTD benefits if your condition is episodic?
Yes. An episodic condition can qualify for LTD benefits if its symptoms prevent you from working as required by your policy. The fact that symptoms fluctuate does not automatically disqualify you from receiving disability benefits.
Does a chronic condition have to be permanent to qualify for LTD?
Not necessarily. Eligibility depends on the definition of disability in the insurance policy and the medical evidence supporting the claim. A condition does not necessarily have to be permanent for a person to qualify for disability benefits.
What medical evidence is needed for an LTD claim involving a chronic condition?
Medical evidence should establish the diagnosis, symptoms, treatment and, most importantly, the functional limitations caused by the condition. The evidence should explain how those limitations affect your ability to perform your job.
Why would an insurance company deny an LTD claim for an episodic disability?
An insurer may question whether the claimant’s current symptoms are sufficiently severe to prevent them from working, particularly where the claimant previously managed the condition while working. Strong medical evidence explaining the change in symptoms and resulting functional limitations can be important in addressing this issue.
Should I keep a symptom diary for my disability claim?
A symptom diary can be useful. It can help you and your healthcare providers identify patterns, changes in symptoms and the effect those symptoms have on your daily activities and ability to work. It should complement, rather than replace, medical evidence.
What should my doctor say about my chronic condition for an LTD claim?
Your doctor should provide an accurate medical assessment and explain your diagnosis, symptoms, treatment, functional limitations and how those limitations affect your ability to perform your occupation. Medical documentation should be specific to your circumstances rather than simply stating that you are unable to work.
What should I do if my LTD claim is denied?
If your long-term disability claim is denied, review the insurer’s denial carefully and consider obtaining legal advice before deciding how to respond. A disability lawyer can assess the policy, medical evidence and reasons for denial and advise you about potential next steps.
What is the elimination period in long term disability insurance?
The elimination period is the waiting or waiting period before long term disability benefits start to be payable. Many policies have an elimination period of 90 to 120 days, during which time you may rely on sick leave or short term disability benefits. You must be totally disabled throughout the elimination period to qualify for LTD payments.
How long can you receive long term disability benefits for chronic conditions?
The maximum benefit period for long term disability insurance varies by policy, but many plans pay benefits until age 65 or until you recover. It is important to understand your policy’s benefit period and any two year limitation period that may affect your claim.
