Complex Regional Pain Syndrome (“CRPS”) is a profoundly debilitating condition that can cause intense pain and a cascade of physical and cognitive symptoms. This complexity often makes navigating the world of disability insurance claims particularly challenging for CRPS sufferers.
If you are considering filing a short or long term disability claim for CRPS, understanding your rights and the processes involved in securing benefits is crucial. In this article, we’ll discuss strategies for getting your CRPS short or long term disability claim approved, common reasons insurance companies deny CRPS claims, and how The Maddox Firm can help.
How Does Complex Regional Pain Syndrome (CRPS) Cause Disability?
Complex Regional Pain Syndrome (“CRPS”) is a chronic pain condition that typically arises after an injury, surgery, stroke, or heart attack. The pain is disproportionate to the initial injury’s severity and is believed to be caused by dysfunction in the central or peripheral nervous systems.
CRPS can cause a range of potentially disabling symptoms that impact both physical and cognitive functions, including:
Severe, persistent pain: Often described as a burning, stabbing, or throbbing sensation, this pain can severely limit the use of the affected limb, making tasks requiring manual dexterity or prolonged physical activity difficult or impossible.
Changes in skin texture: Skin may become shiny and thin, making it sensitive to touch and susceptible to injury, which can impede handling materials or wearing standard work attire.
Changes in skin color and temperature: These can indicate underlying disturbances in blood flow and nerve control, which might deter physical activity due to pain or discomfort.
Swelling and stiffness in affected joints: This can restrict mobility, impairing the ability to perform common job functions that involve movement or maintaining certain postures.
Motor disability: Muscle spasms, weakness, and decreased mobility can make it challenging to perform tasks that require strength or fine motor skills, while tremors or dystonia (abnormal muscle postures) can further complicate precise hand movements or sustained physical activities.
Memory problems: Difficulty recalling information can disrupt routine tasks and responsibilities, affecting professional performance.
Difficulty concentrating: The “brain fog” associated with CRPS can hinder the ability to focus, analyze, or make decisions, which is critical in almost all occupational roles.
Emotional changes: Depression and anxiety, common in chronic pain conditions like CRPS, can exacerbate cognitive impairments and affect motivational levels, further diminishing work capacity.
These symptoms not only cause significant pain and physical discomfort but also severely limit your ability to perform work-related tasks and daily activities. The combination of physical limitations and cognitive impairments makes it difficult for individuals with CRPS to maintain employment, particularly in roles that require consistent physical activity, precise motor skills, or high levels of cognitive function. This profound impact on daily and occupational functioning often necessitates consideration for short or long term disability benefits.
Can CRPS Qualify Me for Short or Long Term Disability Benefits?
Complex Regional Pain Syndrome (“CRPS”) can indeed qualify you for short or long term disability benefits, depending on the severity of your symptoms and their impact on your ability to work. When applying for these benefits, understanding the definitions of disability in your policy—particularly “own occupation” versus “any occupation”—is crucial.
Own Occupation: Under this definition, you are considered disabled if CRPS prevents you from performing the duties of your specific occupation. For example, if you are a surgeon and CRPS affects the steadiness of your hands or your ability to stand for long periods, you might be considered disabled even if you could perform less demanding work.
Any Occupation: This definition is broader and often applies after you receive benefits under the “own occupation” definition for a certain period (typically 24 months). You are considered disabled only if CRPS prevents you from performing the duties of any job suitable for you based on your education, experience, and skill level. This means that even if you can no longer perform your current job, you must also demonstrate that your condition is severe enough to prevent you from doing any other job for which you are qualified.
To qualify for disability benefits for CRPS, you must prove that your condition’s severity and frequency significantly impair your ability to perform your occupational duties. This involves demonstrating that the symptoms—whether pain, motor dysfunction, or cognitive issues—are profound and persistent enough to prevent you from fulfilling the core responsibilities of your job. Your insurance company will consider your specific job requirements and how your symptoms directly impact those duties.
Understanding these distinctions and what you need to prove can help you navigate the process of applying for short or long term disability benefits due to CRPS effectively.
What Evidence Can Support My CRPS Short or Long Term Disability Claim?
To support your short or long term disability claim for Complex Regional Pain Syndrome (“CRPS”), comprehensive evidence is essential. This evidence typically includes medical records, diagnostic tests, and evaluations, as well as vocational and personal documentation that collectively demonstrate the impact of CRPS on your ability to work.
Here are the types of evidence that can strengthen your claim:
Medical Records: Include all records from your primary care provider, pain specialists, neurologists, and any other healthcare professionals involved in your treatment. These records should detail your diagnosis, treatment regimen, response to treatment, and any notes on your reported pain levels and physical limitations.
Diagnostic Testing: CRPS can be elusive in standard medical imaging, but certain tests can support your diagnosis:
Bone Scans: May show alterations in bone metabolism.
MRI Scans: Can detect changes in soft tissues and bones.
Thermography: Measures skin temperature and blood flow to the affected areas, showing abnormalities that support a CRPS diagnosis.
Sympathetic Nervous System Tests: Such as sweat production tests, which can indicate autonomic dysfunction associated with CRPS.
Functional Capacity Evaluation (“FCE”): This is a series of tests conducted by a physical therapist or occupational therapist to assess your physical abilities and limitations. An FCE can document the specific ways CRPS impacts your functional capacity, such as reduced strength, impaired mobility, and decreased tolerance for activities.
Neuropsychological Evaluation: Since CRPS can affect cognitive functions due to chronic pain or related stress, a neuropsychological evaluation can assess your cognitive impairments. This evaluation helps to document issues like memory loss, reduced problem-solving skills, and difficulties with concentration, which are relevant to your occupational capabilities.
Vocational Evidence: Includes an analysis of your job demands compared to your current physical and mental capabilities. A vocational expert report can provide insights into the nature of your work and why your specific symptoms make it impossible to meet these demands.
Witness Statements: Statements from coworkers, family members, and friends can provide firsthand accounts of how CRPS affects your daily activities and job performance. These personal insights can underscore the real-world impacts of your symptoms.
Personal Affidavits: Your own written statements detailing your experience with CRPS, including the pain and limitations you face, how the condition affects your daily life, and your inability to perform specific job functions.
Collecting and presenting a comprehensive package of these types of evidence can significantly enhance the credibility of your disability claim for CRPS, illustrating not only the medical reality of your condition but also its practical effects on your life and work.
How Can A Symptom Diary Document My CRPS Symptoms Effectively for a Short or Long Term Disability Claim?
Effectively documenting your Complex Regional Pain Syndrome (“CRPS”) symptoms is critical when applying for disability benefits. One of the most effective tools for this is maintaining a detailed symptom diary. This diary serves to substantiate the subjective symptoms of CRPS, providing a day-to-day record that can demonstrate the consistency and severity of your condition over time.
Your symptom diary should include:
Date and Time of Each Entry: Maintain regular entries to show the ongoing nature of your symptoms.
Detailed Description of Pain: Note the intensity, type (e.g., burning, throbbing), and specific location of the pain. Use a pain scale from 1 to 10 to quantify the severity.
Physical Symptoms: Record any swelling, changes in skin color or temperature, stiffness, or other physical manifestations. Note how these symptoms vary throughout the day.
Functional Limitations: Document specific activities or tasks you were unable to perform due to your symptoms. Include any difficulties you face with daily activities like walking, standing, or using your hands.
Emotional and Cognitive Effects: Note any feelings of anxiety or depression caused by your CRPS symptoms, as well as any cognitive difficulties like memory lapses or concentration problems.
Medications and Treatments: Keep track of what medications you take, the dosages, and the effects (both positive and adverse) they have on your symptoms.
Doctor Visits and Medical Consultations: Record the dates of medical appointments and key points discussed or treatments prescribed during these visits.
The more detailed your entries, the more they can help in illustrating the real impact of CRPS on your daily life. Regular, consistent entries make your diary a more reliable source of evidence. They show the chronic nature of CRPS and help establish a pattern that can be critical in demonstrating the disability’s impact over time. When submitted alongside your medical records, your symptom diary can help substantiate your CRPS symptoms.
What Are the Challenges in Obtaining Short or Long Term Disability Benefits for CRPS?
Obtaining short or long term disability benefits for Complex Regional Pain Syndrome (“CRPS”) can be challenging due to several factors that might lead to claim denials by insurance companies. Understanding these common reasons for denial can help you prepare a stronger claim.
Here are some of the primary challenges and reasons for denial:
Lack of Objective Evidence: CRPS is diagnosed based on clinical observations and patient reports, which are subjective. Insurance companies often require objective evidence (like blood tests or imaging) that conclusively demonstrates the presence of a condition. Because CRPS doesn’t always manifest in ways that are measurable by standard medical tests, claims can be denied due to an apparent lack of objective evidence.
Vague or Inconsistent Documentation: Incomplete or inconsistent documentation of CRPS symptoms, treatment responses, and impacts on daily functioning can lead to claim denials. Insurance companies may interpret any discrepancies or gaps in medical records as an indication that your condition is not severe enough to warrant disability benefits.
Failure to Meet Policy Definitions of Disability: If your documentation does not clearly establish that CRPS prevents you from performing the duties of your occupation (under the “own occupation” definition) or any occupation (under the “any occupation” definition, usually after the initial benefit period), your claim may be denied. Insurance companies rigorously assess whether your symptoms genuinely restrict your ability to work as defined by the policy.
Disagreement Over Medical Opinions: Insurance companies may rely on the evaluations of their own medical experts, who may disagree with your healthcare provider’s conclusions about your disability. These company-appointed experts might downplay the severity of your symptoms or suggest that you are capable of working despite your condition.
Issues with Treatment Compliance: Insurers expect that claimants will follow prescribed treatments to mitigate symptoms, which is a requirement of most disability insurance policies. If you are not following or responding to the treatment plan as documented by medical providers, your insurance company may claim that you are not doing enough to improve your condition, leading to a denial.
Addressing these challenges directly—through detailed, consistent medical documentation, clear evidence of treatment compliance, and strong support from medical professionals—can improve your chances of obtaining short and/or long term disability benefits for CRPS.
How Should I Handle a Short or Long Term Disability Claim Denial Related to CRPS?
If your short or long term disability claim related to Complex Regional Pain Syndrome (“CRPS”) has been denied, it’s natural to feel disheartened and frustrated. However, it’s important to know that a denial is not the end of the road—you have the right to challenge this decision through the internal appeals process with the insurance company.
Here are the first steps you should consider to effectively handle a short or long term disability claim denial:
Review the Denial Letter Carefully: This letter from your insurance company should explain why your claim was denied and how long you have to appeal the decision. Understanding the specific reasons for the denial is crucial as it will guide your appeal strategy.
Request Your Claim File: You are entitled to request a complete copy of your claim file from the insurance company. This file includes all the documents, records, and other information the insurer used to make their decision. Reviewing this file can help you and your long term disability attorney understand any gaps or weaknesses in the evidence that were used against your claim.
Consult with a Long Term Disability Insurance Attorney: A long term disability lawyer with experience in ERISA can provide invaluable guidance and representation through the appeals process. They understand the complexities of disability law and how to counter the reasons for denials, particularly with conditions like CRPS that may not be well-understood by insurance companies.
It’s highly advisable not to handle the appeal process on your own. The nuances of insurance law and the specifics of CRPS can make navigating a denial challenging without professional assistance. A skilled attorney can help ensure that your appeal is as strong as possible, maximizing your chances of a successful outcome.
How Can The Maddox Firm Prove My Short or Long Term Disability Claim?
At The Maddox Firm, we understand the complexities and challenges that come with pursuing short or long term disability claims for conditions like Complex Regional Pain Syndrome (“CRPS”). Our experienced team is dedicated to providing comprehensive legal support to ensure that your rights are protected and your claim is effectively presented.
We Examine Your Policy and Assess Your Claim: Our first step is to thoroughly review your insurance policy to understand the specific definitions and provisions related to disability claims. For CRPS claimants, we focus on identifying how the policy’s terms can support your unique situation, considering the nuances of CRPS and its impact on your ability to work.
We Handle All Communications with Your Insurance Company: Dealing with insurance companies can be overwhelming, especially when you are managing a condition as challenging as CRPS. We take over all communications with your insurance company, ensuring that your interactions are professional, timely, and documented, which helps prevent any miscommunications that could adversely affect your claim.
We Help You Obtain Evidence to Support Your Claim: Evidence is key in substantiating a disability claim for CRPS. We assist you in gathering comprehensive medical records, organizing detailed symptom diaries, and coordinating with medical professionals to obtain necessary medical assessments and reports. Our aim is to compile a robust evidence package that effectively demonstrates the severity of your symptoms and their impact on your daily and professional life.
We Handle Appeals and Litigation: Should your claim be initially denied, we are prepared to handle the appeals process and, if necessary, pursue litigation. Our approach is tailored to combat the common reasons for denial of CRPS-related claims, focusing on providing clear, strong arguments backed by solid evidence and expert testimonials.
A short term disability or long term disability claim for Complex Regional Pain Syndrome can be a complicated process. If you need help during the claims process, with appealing a claim denial, or with litigating a final adverse short term or long term disability decision, The Maddox Firm can help. The experienced team at The Maddox Firm will examine your insurance policy, correspondence from your insurance company, medical records, and any other relevant documentation in order to give you personalized guidance on how we can help you win your short and/or long term disability claim. Our New Jersey and New York long term disability attorneys help clients nationwide.