Daily Archives: October 2, 2017

Subjective Conditions Limitation Provisions

In previous posts we’ve talked about mental health limitation provisions.  In this post, we are going to discuss a similar type of provision:  subjective symptom limitation provisions.

What are Subjective Symptom Conditions?

Insurance companies typically invoke these types of provisions when a claimant describes a disability or condition based upon self-reported symptoms, without producing objective medical evidence to back up the reported symptoms.  This can occur in situations where there is no standard accepted medical test to confirm a diagnosis, or when tests do not return any confirming or conclusive results, or when a claimant has not properly developed his or her medical records and/or simply neglected to have objective testing done.

We most often see these types of limitations in ERISA policies, but they are becoming more and more common in individual policies.  An example from an actual policy defines subjective symptoms as follows:

Some examples of conditions an insurance company might contend are encompassed by this provision include:

  • Fibromyalgia
  • Chronic Fatigue Syndrome
  • Sleep Apnea
  • Paresthesia/Dysesthesia
  • Carpal Tunnel Syndrome
  • Myofascial Pain Syndrome
  • Lyme Disease
  • Orthopedic Conditions
  • Temporal Lobe Phenomenon
  • Vertigo
  • Migraine
  • Tinnitus
  • Irritable Bowel Syndrome
  • Osteopathic and Rheumatoid Arthritis
  • Generalized Pain
  • Epstein-Barr Syndrome
  • Valley Fever

Insurers also use these limitation provisions to argue that other conditions should be limited, even when there is some objective evidence.  For example, a dentist suffering from a musculoskeletal condition might report to his or her doctor that he or she is experiencing neck pain, or lower back pain. The doctor might order an MRI, which might show that the dentist has some issues in his or her cervical or lumbar spine, but even with the MRI imaging, it can sometimes be difficult to pinpoint the precise cause of the symptoms that are being reported.  Insurers know this and target these types of claims because, under a broad reading of the policy provision, they involve subjective reports of pain and the  physical source of the pain cannot always be conclusively verified using tests.

Why is this provision important to know about?

These limitations typically cap benefits that will be paid out, generally at 12 to 24 months.  After this mark has been reached, no additional benefits will be issued even if your symptoms continue and you cannot return to work.  In other words, a policy you thought would last for the maximum benefit period can end up being good for as little as a year.

Insurance companies want to avoid paying out claims and often construct policies in a manner that allows them to restrict or deny coverage. This can include hiding limitations at the end of a policy or in a vaguely worded provision.  It is not enough to simply look at a policy’s schedule page, because a limitation provision may actually be much broader limitation than you might think when you read “mental/nervous limitation” in your policy summary.  Subjective condition limitation provisions are often combined with mental health and substance abuse limitation provisions, so it is easy for a policy holder to skip over this sort of provision when scanning through his or her policy, assuming that it only applies to mental health disorders or alcohol/addiction issues.

The Takeaway

When invoking these limitations, the insurance company is not denying that a claimant has an illness or even that it prevents a policyholder from working.  Rather, the insurance company is seeking to take advantage of the limits of medical science and/or lack of agreement in the medical community regarding finding and establishing guidelines regarding conditions like the examples listed above. They then use the subjective condition provision to cast doubt on a claim and complicate the claim procedure.  Often, they will use multiple in-house physicians to contradict a claimant’s own physician and medical records.

Fighting an insurance company’s decision to classify a condition as subject to this provision can be a costly and long process, and can turn into an expensive war of attrition that can often end in litigation. For these reasons, these types of claims must be handled with care from the start and require the assistance of a supportive doctor to properly document and treat the condition.

When purchasing a policy, it is important to watch out for subjective symptom condition limitation provisions.  Always be sure to read your policy or potential policy carefully so that you understand the scope of the your protection.