Back pain is one of the most common causes for filing a long-term or short-term disability insurance claim. This condition involves a wide range of conditions. Usually, insurance companies assess eligibility for benefits due to back pain in the same way, regardless of the medical basis for the pain. Complicating the insurance company's assessment further is the fact that most cases of back pain have an unknown etiology. Most doctors do not understand the leading cause of the pain. Insurance companies consider claims based on back pain as one of “self-reports” with no objective evidence to support a level of impairment that will lead to disability. Seek the services of an experienced attorney if you have a challenge securing long-term disability benefits for back problems.
Back Problems That Qualify For Long-Term Disability Benefits
Back problems can qualify for disability benefits if they are medically documented, long-term, severe, and significantly affect a person’s ability to work or carry out daily activities. The typical back problems that can qualify for disability benefits include:
Chronic Radiculopathy
Persistent nerve pain caused by spinal nerve compression can qualify for long-term disability benefits. However, eligibility depends on muscle weakness, reflex loss, documented nerve damage, and ongoing limitations despite treatment.
Cauda Equina Syndrome
Cauda equina syndrome is a severe case involving compression of the nerve roots at the lower end of the spinal cord. Some of the severe symptoms include numbness in the saddle area, severe weakness in the legs, and loss of bowel or bladder control. Permanent neurological damage from this case qualifies for disability.
Severe Scoliosis
An abnormal curvature of the spine characterizes severe scoliosis. This condition can qualify for long-term disability benefits if:
- Nerve compression symptoms are present
- Chronic pain that restricts you from working
- Causes breathing issues, and
- Severe and progressive curvature
You will not qualify for long-term disability benefits if you have mild scoliosis unless functional impairment is significant.
Ankylosing Spondylitis
Ankylosing Spondylitis is an inflammatory autoimmune disease that causes spinal fusion over time. Some qualifying features include systemic symptoms, limited neck and lower back movement, reduced chest expansion, and significant spinal stiffness. Severe spinal immobility qualifies for long-term disability benefits.
Spinal Fractures
Accidents, osteoporosis, and trauma can cause spinal fractures. This can qualify for long-term disability benefits if:
- You experience chronic severe pain despite treatment
- The spinal cord is involved
- You have long-term mobility problems, and
- You have compression fractures causing deformity
Failed Back Surgery Syndrome
In some situations, back surgery does not relieve pain or can make the symptoms worse. You will qualify for long-term disability benefits if:
- You have functional limitations that prevent you from going to work
- You have ongoing neurological deficits
- You have scar tissue compressing nerves, and
- You are experiencing persistent pain after surgery
Spondylolisthesis
Spondylolisthesis is a condition in which one vertebra slips forward over another. You will be eligible for long-term disability benefits if:
- You have a severe instability that needs surgery
- Failure of conservative medication
- You have limited spinal mobility
- You have nerve compression symptoms, and
- Chronic back pain
Spinal Stenosis
Spinal stenosis is a condition characterised by the narrowing of the spinal canal that compresses the spinal cord or nerves. Other symptoms include:
- Difficulty balancing
- Weakness or numbness in the legs
- Relief when sitting or bending forward, and
- Pain when standing or walking
This condition can qualify for long-term disability benefits if:
- You have a persistent neurological impairment
- You have a challenge walking without help, and
- You have documented spinal narrowing on imaging
Degenerative Disc Disease
Degenerative Disc Disease involves the gradual breakdown of spinal discs because of wear and tear or aging. You can be eligible for long-term disability benefits if:
- You are unable to carry out work-related activities like prolonged sitting, bending, and lifting
- You have a reduced range of motion
- Imaging shows disc narrowing or collapse, and
- You are experiencing persistent pain despite treatment
Severe cases causing spinal stability or nerve compression also qualify for long-term disability benefits.
Herniated Disc
You can suffer a herniated disc if the soft inner section of a spinal disc pushes through the outer layer and presses on the surrounding nerves. A herniated disc qualifies for long-term disability benefits if:
- You are experiencing symptoms like limited ability to stand, sit, or walk, muscle weakness, numbness or tingling, and radiating pain
- You have a nerve root compression confirmed by a CT scan or an MRI, and
- You have chronic, severe back pain that has lasted for one year or more
You will be eligible for long-term disability benefits if a herniated disc significantly limits your mobility or causes persistent neurological deficits.
The Evidence Required For Securing Long-Term Disability Benefits For Back Problems
Some of the evidence you can use to secure long-term disability benefits for back problems include:
Consistent Documentation Over Time
A solid case has the following:
- Up-to-date assessment and treatment records
- Consistent reporting of limitations and pain, and
- Regular visits to the doctor
Mistakes can make your claim weak and invite skepticism.
Vocational Expert Reviews
You should obtain vocational expert reviews, particularly for Social Security Disability. The expert reports analyze your ability to work and evaluate the labor market. The medical expert will also provide ratings of transferable skills. Vocational expert reviews help show long-term or permanent inability to work.
Statements From others
The following can support your claim:
- Supervisor or coworker letters regarding work performance decline
- Roommate or family statements about your daily struggles, and
- Your statements regarding how the condition has affected your life
The above statements should include consistency with your medical records, specific activities affected, and clear examples.
Your Work History And Job Demands
You should provide evidence about how your disability prevents essential job functions. Information about your employer's specific physical requirements and your job descriptions is also necessary. Some programs demand that your provider give reasons why you are unable to discharge your duties now or ever. This is important because it links medical evidence to real work restrictions.
Functional Limitations And Daily Impact
Provide records highlighting how your back problems affect your ability to work and function. Some of the limitations include:
- You require regular rest breaks
- Difficulty with basic movements
- Inability to lift more than a light weight
- Inability to stand or sit longer than a short period.
Request your doctor to complete work capacity forms, physician questionnaires, or report forms. The doctor should also complete Functional Capacity Evaluations (FCE).
Treatment History
You should provide records showing the following:
- Referrals and consultations
- Surgical interventions, if any
- Injections
- Physical therapy records, and
- Treatment tried
You should also provide treatment response documentation indicating what helped, what did not help, side effects, and functional effects. This is important because it shows that you have tried all acceptable medications.
Specialist Reports
Solid evidence always includes assessments by the following individuals:
- Pain management doctors
- Physical medicine specialists
- Neurosurgeons, and
- Orthopedic spine surgeons
The above professionals add credibility and detailed medical opinions. Doctors' reports are given greater weight than general provider notes.
Clinical Notes And Progress Records
Request your doctor to provide the following copies:
- Neurological exams
- Range of motion testing
- Pain assessments, and
- Exam notes from every visit
The above copies should include the following:
- Objective findings like medical evidence noted by the clinician, and
- Subjective complaints like severity, location, and how it impacts your daily life.
Consistent clinical records indicate ongoing disability.
Imaging And Test Results
You should provide the following copies:
- CT scans
- X-rays
- MRI scans, and
- EMG or nerve conduction studies (NCS)
The above imaging will reveal the following:
- Degeneration or structural abnormalities
- Nerve compression
- Herniations, and
- Any correlation between imaging findings and symptoms
Imaging often reveals structural issues in your spine.
Comprehensive Medical Records
Provide diagnosis documentation that shows the following:
- The specific diagnosis, including degenerative disc disease or herniated disc
- Diagnostic codes, like ICD-10 codes, if available, and
- Dates of diagnosis and treating provider
The above shows that a healthcare provider formally recognizes your problem.
Factors That Determine Long-Term Disability Approval For Back Problems
Disability approval is not based on diagnosis alone, but it is based on functional impairment and inability to work. Some of the factors that are considered include:
Independent Medical Exams (IME) And Reviews
Your insurance company can request file reviews by hired physicians, surveillance, and an independent medical examination. Inconsistencies at the time of assessment can negatively impact approval.
Policy Definition Of Disability Under Private Insurance
Private insurance companies have the following definitions:
- ‘’Own occupation’’ where you cannot carry out your specific duty, and
- ‘’Any occupation’’ where you cannot engage in any work suited to your education and experience
It will be challenging to maintain a claim if policies move from ‘’own occupation ''to "any occupation’’.
Mental Health Impact
Chronic back pain can lead to sleep disorders, anxiety, depression, and cognitive impairment because of pain or medication. The above can strengthen your claim if appropriately documented.
Age, Education, and Transferable Skills
The following will be considered under government disability programs:
- Ability to transition to less demanding work
- Your previous work experience
- Your educational level
- Your age
Older people with less education and a history of physical work always have stronger cases.
Credibility And Consistency
Decision-makers often take into account the following:
- Whether the activities of your daily living contradict your disability claims
- Whether your symptoms match the assessment findings, and
- Consistency between medical records and your statements
Medical Opinions
Strong supporting documentation will be considered, including:
- Clear reasons why you cannot work
- Reports from a pain specialist, a neurologist, and an orthopedic surgeon
- Functional Capacity Evaluation (FCE)
- Detailed physicians statements
Your claim will be approved if your doctor presents specific limitations or opinions that are consistent with medical records.
Duration Of Disability
Permanent impairment or a condition that takes one year or more will be considered. Short-term disability will not qualify.
Job And Occupation Demands
The classification of your job matters. If your work is more physical, your claim is likely to be approved, especially if you stand for long hours, engage in repetitive bending, or carry heavy loads. If your work is sedentary, it could be challenging for your claim to be approved unless:
- Treatment side effects impair your performance
- You are unable to maintain focus because of pain, and
- You cannot sit for long
The insurance company will compare your job requirements with your Residual Functional Capacity (RFC).
Functional Limitations
Functional limitation is often the determining factor. The following abilities will be assessed:
- Maintaining concentration because of pain
- Using arms or hands repeatedly
- Kneeling, stooping, or bending
- Carrying or lifting a weight
- Walking or standing, and
- Sitting for extended periods
A diagnosis is not enough. You must provide specific work-related limitations, such as:
- Lying down during the day
- Regular rest breaks
- Inability to lift more than five to ten pounds, and
- Inability to sit for more than 20-30 minutes
Response To Treatment
Before your claim is approved, the following will be considered:
- Whether your symptoms are chronic despite aggressive care
- Whether the treatment is controlling back pain effectively
- Whether the surgery corrected the back issue, and
- Whether your symptoms improved with treatment
Your claim could be approved if the treatment has been extensive and the symptoms persist despite compliance.
Consistency Of Treatment
Your claim will only be approved once the following determination has been made:
- Whether you take medications as directed
- You have attempted the recommended therapies
- You have observed prescribed treatment, and
- You seek regular medical care
Gaps in your medication could indicate that your situation is not serious.
Severity Of Medical Condition
The decision-makers will assess the objective medical evidence that includes:
- Post-surgical complications
- Degenerative disc disease
- Disc herniation
- Spinal stenosis, proof of nerve root compression, and
- MRI, CT scan, or X-ray findings
Clinical findings will also be evaluated, which include:
- Abnormal gait
- Positive straight-leg raise test
- Sensory deficits
- Reflex loss
- Muscle weakness, and
- Reduced range of motion
Your claim could be rejected if your condition is mild without physical exam abnormalities. The other reasons for claim denial include:
- Ability to carry out sedentary work
- Your back pain is expected to improve
- Lack of documented functional limitations
- Inconsistent statements
- Failure to follow treatment
- Gaps in medication, and
- Insufficient objective evidence
Find A Reputable Disability Benefits Attorney Near Me
Back pain can have far-reaching effects on your life, making it challenging to execute daily tasks. Proving your disability due to back pain can be difficult, especially if you choose to pursue the benefits without the help of an attorney. For the best outcome, you should contact a disability benefit attorney to guide you through the claim process.
At Leland Law, we have competent attorneys who can help you pursue disability benefits for back problems in California. Contact us at 866-449-6476 to speak to one of our attorneys.
