Long-Term Disability Claims:  How Medical Evidence Helps You Win Your Case

When you’re unable to work due to a serious illness or injury, long-term disability (LTD) benefits can provide much-needed financial support during an incredibly challenging period. However, securing LTD benefits isn’t always straightforward or simple. Insurance companies are notorious for scrutinizing LTD claims, and the difference between approval and denial may come down to a critical factor: the quality of your medical evidence and supporting documentation.

Understanding how medical evidence supports your claim and knowing what documentation you need can significantly improve your chances of success.

Why Medical Evidence Is Considered the Foundation of a Viable LTD Claim

Long-term disability insurance policies typically require claimants to submit evidence reflecting the fact that they cannot perform the duties of their occupation due to a medical condition. Unlike some other types of insurance claims, disability determinations are rarely clear-cut. Insurance adjusters cannot see chronic pain, measure fatigue, or experience cognitive impairment firsthand. They rely entirely on medical documentation to understand the severity and impact of your condition.  In fact, being under the “active” or “regular” care of physicians and specialists is often a requirement for benefits in the policy.

Without robust medical evidence, even legitimate disabilities may appear questionable to insurance companies. Conversely, comprehensive documentation from qualified healthcare providers creates a compelling narrative that demonstrates not only your diagnosis but also how your condition prevents you from working. Medical evidence serves as the objective foundation that substantiates your subjective experience of disability.

Types of Medical Evidence That Matter Most

Not all medical documentation carries equal weight in disability claims. Insurance companies look for specific types of evidence that clearly establish both your diagnosis and your functional limitations. Examples of notable pieces of medical evidence that can bolster your LTD claim include the following:

• Clinical notes and treatment records: These documents should detail your symptoms, the progression of your condition, treatments attempted, and your response to those treatments. Regular, consistent medical care demonstrated through detailed records shows that your condition is genuine, ongoing, and significant enough to require continuous professional attention.
• Diagnostic test results: MRIs, CT scans, X-rays, blood work, nerve conduction studies, and other diagnostic procedures offer measurable evidence of pathology. For conditions like herniated discs, multiple sclerosis, or cancer, these tests provide indisputable proof of a medical problem that cannot be dismissed as subjective.
• Specialist evaluations: A rheumatologist’s assessment of fibromyalgia or lupus, a neurologist’s evaluation of traumatic brain injury, or a psychiatrist’s diagnosis of severe depression demonstrates that experts in the relevant field have confirmed your condition. Specialists can also provide detailed opinions about how your specific condition affects your ability to work.
• Functional capacity evaluations (FCEs): An FCE measures what you can and cannot do physically. These assessments, typically conducted by physical or occupational therapists, provide objective data about your lifting capacity, endurance, range of motion, and ability to perform work-related tasks. For physical disabilities, FCEs can be particularly persuasive evidence.
• Mental health documentation: Psychological testing results, therapy notes, and psychiatric evaluations help quantify conditions that are inherently subjective. Assessments that describe cognitive impairments, concentration difficulties, or social functioning limitations connect mental health diagnoses to work-related capabilities.

The Attending Physician’s Statement: An Important Document

Most insurance companies require an Attending Physician’s Statement (APS) as part of the claim process. This form, completed by your primary treating physician, asks specific questions about your diagnosis, symptoms, treatment, and functional limitations. The APS often becomes the single most influential document in claim determinations.

Your physician should complete this form thoroughly and precisely. Vague statements like “patient cannot work” provide little value. Instead, effective statements specify exactly which work activities you cannot perform and why. For example, “Patient cannot sit for more than 30 minutes at a time due to chronic lumbar radiculopathy” or “Patient’s concentration deficits secondary to major depression prevent sustained attention required for data analysis” provide concrete, actionable information.

It’s crucial to meet with your physician before they complete the APS to ensure they understand your occupation’s specific demands. A physician who knows you work at a computer all day can better address whether your condition prevents prolonged sitting or computer use. Clear communication between you and your doctor results in more accurate and helpful documentation.

Consistency and Continuity in Medical Records

Insurance companies scrutinize medical records for consistency. Gaps in treatment, contradictory information, or statements that suggest you’re more functional than claimed can derail otherwise valid claims. Maintaining regular medical care throughout your disability demonstrates that your condition requires ongoing attention and remains severe.

Avoid missing appointments when possible, and ensure you honestly report your symptoms and limitations to all healthcare providers. If you tell your doctor you’re doing better but tell the insurance company you’re completely disabled, the inconsistency will likely result in denial. Likewise, if your medical records show you engaged in activities that seem incompatible with your claimed limitations, be prepared to explain these discrepancies.

The Role of Residual Functional Capacity Assessments

Many disability policies require proof that you cannot perform not just your current job but any occupation for which you’re reasonably qualified. This makes residual functional capacity (RFC) assessments particularly valuable. An RFC describes what you can still do despite your limitations, such as standing for limited periods, lifting specific weights, or working in low-stress environments.

A detailed RFC assessment from your physician helps insurance companies understand the specific restrictions your condition imposes. These assessments should address physical capabilities like lifting, walking, and sitting, as well as mental capabilities like concentration, memory, and stress tolerance. The more specific your RFC, the more clearly it demonstrates that your limitations prevent substantial gainful employment.

When Additional Evidence Becomes Necessary

If your initial claim is denied, additional medical evidence often becomes necessary for appeals. Independent medical examinations, additional specialist consultations, or updated diagnostic testing may strengthen your case. Sometimes, consulting a different specialist who can provide a fresh perspective on your condition helps clarify aspects that were previously poorly documented.

Vocational assessments that analyze how your specific limitations affect your employability can also supplement medical evidence. These evaluations connect your medical restrictions to real-world job requirements, demonstrating why your limitations prevent you from maintaining employment.

Building Your Medical Evidence Strategy

Successful disability claims require proactive collaboration with your healthcare providers. Keep copies of all medical records, test results, and correspondence. When you visit doctors, clearly describe how your symptoms affect your daily activities and work capacity. Ask providers to document specific functional limitations in your chart.

Consider maintaining a symptom journal that tracks pain levels, fatigue, cognitive difficulties, and how these symptoms interfere with daily activities. While personal journals aren’t medical evidence per se, they can help you communicate more effectively with your physicians, resulting in better documentation.

Have Questions? Speak to an Experienced LTD Benefits Lawyer Today

Medical evidence is the cornerstone of every successful long-term disability claim. Comprehensive documentation from qualified healthcare providers, including detailed treatment notes, objective diagnostic results, specialist evaluations, and functional assessments, creates a persuasive case that your condition prevents you from working. 

A knowledgeable and experienced LTD benefits attorney with Bross Frankel PA can help ensure that you get the benefits you are entitled to under the terms of your insurance policy. An attorney will proactively evaluate your LTD policy, analyze the available medical evidence and other supporting documentation, and suggest additional ways to strengthen your LTD claim.

To learn more or to schedule a free claim review with a New Jersey long-term disability attorney, give us a call at 856-795-8880 or fill out our online contact form.