Brachial Plexus Injuries

January 15, 2024

What is a Brachial Plexus Injury?

The branchial plexus is a network of five nerves that sends signals from the spinal cord to the shoulder, arm, and hand. A brachial plexus injury occurs when the nerves are stretched, compressed, or ripped apart or torn away from the spinal cord. More specifically, the types of brachial plexus injuries include:

• Brachial plexus neuropraxia (stretch) – where the nerves are stretched to the point that injury occurs
• Brachial plexus rupture – where the nerve tears either partially or completely
• Brachial plexus neuroma – where scar tissue forms on the nerve
• Brachial neuritis – a rare progressive disorder of the nerves, also called Parsonage Turner syndrome
• Brachial plexus avulsion – where the root of the nerve is completely separated from the spinal cord

What are the Symptoms of a Brachial Plexus Injury?

Symptoms can vary greatly, based on the location and severity of the injury. In most cases, only one arm will be affected.

For less severe, minor injuries (often called stingers or burners) symptoms can include:

• Numbness and weakness in the arm
• An electric shock-like or burning sensation that shoots down the arm

For the most part, these symptoms last only a few seconds to minutes, but in some cases, the symptoms may last for days or longer.

For more severe injuries (those that severely hurt or tear or rupture the nerves), symptoms can include:

• Severe pain
• Weakness or inability to use certain muscles in the shoulder, arm, or hand
• Total lack of movement and feeling in the shoulder, arm, and hand
• An arm that hangs limply

Many brachial plexus injuries heal with time, leaving little lasting damage. However, some injuries cause temporary or permanent complications, which can include:

• Pain resulting from nerve damage, which may become chronic
• Stiff joints
• Muscle atrophy
• Numbness
• Permanent disability, including muscle weakness or paralysis

Some brachial plexus injuries can result in a disorder called Horner’s syndrome. In this syndrome, certain nerves in the sympathetic nervous system are damage, leading to drooping eyelid, an overly constricted pupil, and decreased facial sweating on one side of the face.

What Causes Brachial Plexus Injuries?

Damage to the upper nerves of the brachial plexus occurs when the shoulder is forced down while the neck stretches up and away from the shoulder. Damage to the lower nerves of the brachial plexus occurs when the arm is forced above the head. Injuries such as these can happen in numerous ways, including:

• Trauma, such as automobile accidents or serious falls
• Contact sports
• Tumors and cancer treatments
• Difficult births

How are Brachial Plexus Injuries Diagnosed?

Physicians will often turn to certain tests to diagnose brachial plexus injuries, including:

• X-rays
• EMG (electromyography)
• Nerve conduction studies
• MRI
• CT scans

What is the Treatment for a Brachial Plexus Injury?

Treatment will vary based on severity, type/location of the injury, any other conditions, and the length of time that has passed since the injury. Nerves that have only been stretched may not need further treatment and may recover on their own. Other treatments include:

• Physical therapy
• Occupational therapy
• Corticosteroid creams or injections
• Medications for pain management
• Surgery

There are several types of surgery that may be used when treating brachial plexus injuries, including:

• Muscle transfer
• Nerve transfer
• Nerve graft
• Neurolysis

It can take up to three years for pain from the most severe cases to resolve. Providers may also use a surgical procedure to interrupt pain signals coming from the damaged part of the spinal cord.

A brachial plexus injury can interfere with an individual’s ability to work or carry out daily tasks. If you have been diagnosed with a brachial plexus injury and are worried that it may be impeding your ability to continue to safely practice on patients, you should speak with an experienced disability insurance attorney.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described above and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

Sources

Mayo Clinic

John Hopkins

National Institute of Health

Cleveland Clinic

The Importance of Understanding Policy Definitions:
A Case Study

January 1, 2024

 We’ve discussed before the importance of timelines and reading your policy carefully. This holds true when looking at whether you will be eligible to receive lifetime benefits should you become disabled.

One example of this is the case of Shields v. Provident Life and Accident Ins. Co.[1] (Unum). Dr. Shields was a gastroenterologist who developed health issues including headaches, cervical spine pain, numbness, and spinal stenosis. She became partially disabled on June 1, 2017 and then totally disabled on October 9, 2017. Because Dr. Shields reached age 60 on June 4, 2017, Unum found that she was only eligible for benefits until age 65 (versus lifetime benefits) because she had become totally disabled after she reached the policy-defined age of 60.

“Age”, under the policy, was defined as “the ending date of the policy term in which you attain that age.”  Part of what was at issue in this case was what the “policy term” was.  Unum argued that it was August 31, 2017, because Dr. Shields paid her premiums on a quarterly basis. Dr. Shields argued that the end-date of the policy was actually December 1, 2017, making her 59 at the time of disability and eligible for lifetime benefits, because she understood “renewal premium” to mean the renewal term of the policy schedule (which was 12 months).  At issue here were of several different terms in the policy, including not just “age”, but “policy term”, “renewal premium”, “renewal term” and “premium term”.

As part of the case, Dr. Shields deposed several Unum employees, who actually gave conflicting testimonies that showed the policy was ambiguous when it came to determining Dr. Shield’s age at the time she became totally disabled. In its decision, the court explained that, under Arizona law, ambiguities in an insurance contract will be construed against the insurer, and they found in favor of Dr. Shields.

This case highlights the importance of carefully reading your policy. If you have questions about the timeline of your policy, please feel free to reach out to one of our attorneys directly.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your insurer is not evaluating your claim under the proper standard, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.

[1] Shields v. Provident Life & Accident Ins. Co., No. 1 CA-CV 22-0057, 2022 WL 17164180 (Ariz. Ct. App. Nov. 22, 2022)

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Rotator Cuff Injuries

December 18, 2023

What is a Rotator Cuff Injury?

The rotator cuff is a group of tendons and muscles that surround the shoulder joint. The rotator cuff keeps the head of the upper arm bone firmly in the socket of the shoulder.

Rotator cuff injuries can be the result of a sudden event, or gradual wear and tear over time. They are common and the likelihood of a rotator cuff injury increases with age. A rotator cuff may tear partially or fully. In partial thickness tears, the tendon is not completely severed from the shoulder. With a full-thickness tear, the tendon separates completely from the bone and there is a hole or rip in the tendon.

What are the Symptoms of Rotator Cuff Injuries?

While some rotator cuff injuries don’t cause pain, other injuries may result the following symptoms:

• Pain that is experienced as a dull ache deep in the shoulder
• Recurrent pain, exacerbated with certain activities
• Disturbed sleep
• Difficulty doing certain activities, such as combing hair or reaching behind the back
• Arm weakness
• Limited ability to move the arm
• Grating or cracking sounds during movement of the arm

What Causes Rotator Cuff Injuries?

Rotator cuff injuries are usually caused by the progressive wear and tear of the tendon tissue over time. Overuse, such as repetitive overhead activity or prolonged bouts of heavy lifting (common in certain occupations) can damage or irritate the tendon, and may result in earlier onset of injury. Degenerative tears can also be caused by bone spurs and decreased blood flow. In other instances, the rotator cuff can be injured in a single incident, such as in a fall.

Risk factors include:

• Age – rotator cuff injuries are most common in those over 60
• Occupation – jobs that require repeated overhead reaching may damage the rotator cuff over time
• Sports
• Family history

How are Rotator Cuff Injuries Diagnosed?

Rotator cuff injuries are diagnosed with a variety of techniques, including:

• Physical exams
• X-rays – to rule out other potential causes for pain (e.g. bone spurs or arthritis)
• Ultrasound – to assess the structure of the shoulder during movement, and provide a comparison between the affected and health shoulder
• MRI – to provide detailed images of the structures of the shoulder

What is the Treatment for a Rotator Cuff Injury?

Without proper treatment, a rotator cuff injury could lead to weakness or loss of motion of the shoulder joint. Treatment includes:

• Lifestyle changes such as taking over-the-counter pain medications, icing, and limiting overhead activity and other painful movements
• Physical therapy (both as an initial treatment and after a surgery)
• Ultrasound therapy
• Injections (which provide temporary relief, but can also weaken the tendon and reduce the chance of success of shoulder surgery)
• Surgery

There are several different types of surgeries that may be used to repair rotator cuff injuries, such as:

• Arthroscopic tendon repair
• Open tendon repair
• Tendon transfer
• Shoulder replacement

A rotator cuff injury can interfere with an individual’s ability to work or carry out daily tasks. If you have been diagnosed with a rotator cuff injury and are worried that it may be impeding your ability to continue to safely practice on patients, you should speak with an experienced disability insurance attorney.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described above and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

Sources

Mayo Clinic

John Hopkins

Cleveland Clinic

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Sciatica

November 20, 2023

What is Sciatica?

The sciatic nerve, the largest nerve in the body, travels from the lower back through the hips and buttocks, and down each leg. Sciatica (also called lumbar radiculopathy) refers to pain that travels along the path of the sciatic nerve. It is most common in individuals between the ages of 30 and 50 years old.

What are the Symptoms of Sciatica?

Sciatica pain can occur almost anywhere along the nerve pathway. However, it is especially likely to follow from the low back to the buttocks and the back of a thigh or calf. It typically only affects one side of the body. Pain intensity and severity can vary—anywhere from a mild ache to a burning, sharp pain. For some, the pain will feel like an electric shock or jolt. Numbness and weakness are also present in more severe cases.

Since sciatica is caused by pressure on the spine, complications can develop if the pressure is not relieved, including:

• Increased pain
• Herniated or slipped disc
• Loss of feeling or weakness in the affected leg
• Loss of bowel or bladder function
• Permanent nerve damage

What Causes Sciatica?

Sciatica is most likely to occur when a herniated disc or an overgrowth of bone (bone spurs) puts pressure on the sciatic nerve, which leads to pain, inflammation and often times numbness in the affected leg. Other conditions that can cause sciatica include:

• Degenerative disc disease
• Spinal stenosis
• Foraminal stenosis
• Spondylolisthesis
• Osteoarthritis
• Injury
• Pregnancy

In some cases, diseases, including diabetes, can damage the sciatic nerve. In rare instances, a tumor can be the cause of pressure on the nerve.

Risk factors include:

• Age
• Obesity
• Occupation (including those that require twisting the back, such as in dentistry)
• Prolonged sitting
• Nerve disorders

How is Sciatica Diagnosed?

Initially, a doctor will likely perform a physical exam to look for activities that worsen sciatica pain (walking on toes or heels, rising from a squatting position, or lifting the legs while lying down). Other tests can be used to diagnose sciatica including:

• MRIs – these can show herniated discs and pinched nerves
• X-rays – these can show an overgrowth of bone that could be pressing on a nerve
• CT scan
• EMG (electromyography) – to determine how severe a nerve root injury is

What is the Treatment for Sciatica?

Mild sciatic pain can improve with self-care measures such as ice or heat, stretching, and over-the-counter pain medications. In fact, most people with sciatica get better on their own. However, sometimes additional treatment becomes necessary and can include:

• Anti-inflammatories
• Corticosteroids
• Antidepressants
• Anti-seizure medications
• Opioids
• Physical therapy
• Chiropractic care
• Acupuncture
• Steroid injections

In some instances, when these treatments don’t work, and the sciatica is causing severe weakness, pain, and/or loss of bowel or bladder control, surgery will be an option. During surgery, the bone spur or a portion of the herniated disc pressing on the nerve will be removed.

While it’s not always possible to prevent sciatica, certain measures can be taken to protect the back, including exercising regularly, keeping good posture when sitting, and using the body correctly (e.g., lifting with the legs instead of the back).

Sciatica can interfere with an individual’s ability to work or carry out daily tasks. If you have been diagnosed with sciatica and are worried that it may be impeding your ability to continue to safely practice on patients, you should speak with an experienced disability insurance attorney.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described above and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

Sources

Mayo Clinic

John Hopkins

Cleveland Clinic

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Epstein-Barr Virus

October 23, 2023

What is the Epstein-Barr Virus?

Epstein-Barr virus (EBV) is also known as herpesvirus 4 and is a member of the herpes virus family. It is contagious and easily spreads through saliva, as well as other bodily fluids. While most people get infected with EBV (about 95%) at some point of their lives, some have no symptoms while others will go on to develop other illnesses (such as infections mononucleosis).

In a EBV infection, the virus attaches to white blood cells (lymphocyte B cells). When this happens, the cells become unable to fight infection properly, triggering symptoms.

What are the Symptoms of an Epstein-Barr Infection?

Symptoms can include:

• Fatigue
• Sore and inflamed throat
• Swollen lymph nodes in the neck
• Rash
• Fever
• Swollen liver
• Enlarged spleen

While in most adults symptoms get better in two to four weeks, some may feel fatigued for many weeks or even months. In addition, once infected, the EBV will stay latent in the body and in some cases the virus may re-activate. Those with weakened immune systems, are more likely to develop symptoms if EBV re-activates. Stress and menopause and/or hormone changes can also cause the virus to re-activate.

How is Epstein-Barr Diagnosed?

Because EBV infections have symptoms that are similar to other illnesses, it can be challenging to diagnosis, but it can be confirmed with a blood test that detects antibodies.

What is the Treatment for Epstein-Barr Virus?

While there is no specific treatment for EBV there are ways to relieve symptoms, including:

• Staying hydrated
• Getting rest
• Taking medications (OTC) for pain and fever

What are Complications of Epstein-Barr Virus?

While the Epstein-Barr virus is most commonly associated with mononucleosis, there are other conditions that may be triggered by the Epstein-Barr virus, including:

• Viral meningitis
• Encephalitis
• Optic neuritis
• Transverse myelitis
• Facial nerve palsies
• Guillain-Barre syndrome
• Acute cerebellar ataxia
• Hemiplegia
• Burkitt lymphoma (white blood cell cancer)
• Nasopharyngeal cancer (cancer of the nose and throat)

A recent study out of Stanford also EBV is also a trigger for multiple sclerosis.

EBV and any associated illnesses can interfere with an individual’s ability to work or carry out daily tasks. If you have been diagnosed with EBV or a related condition, and are worried that it may be impeding your ability to continue to safely practice on patients, you should speak with an experienced disability insurance attorney.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described above and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

Sources:

Centers for Disease Control and Prevention
Cleveland Clinic
Banner Health
Stanford

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Mental Health Resources offered by Insurers May Be Used to Terminate Benefits

October 9, 2023

Deciding when, or if, it is safe to return to work after filing a disability insurance claim can be difficult and nuanced, including for mental health claims. Insurance companies, of course, have an incentive to push claimants back to work, so they may place pressure on an insured to do so.

Recently, MetLife announced that it was partnering with Lyra, a provider of workforce mental health services, to provide employees with access to mental health services as part of their recovery when they file a disability claim.

According to a recent news release, the collaboration will connect eligible individuals to Lyra’s providers at the beginning of their claim. The same release indicated that the partnership would provide claimants with more “comprehensive well-being services” during leave, “while also helping employers with the administrative tasks associated with disability claims and mental health resources.”

Depending on the circumstances, this may be helpful and beneficial for individuals facing mental health challenges. However, in our experience, mental health providers connected to a disability insurer can sometimes push for a “return to work” date before the individual is actually ready to do so. Accordingly, it is important to be mindful of ongoing limitations and communicate them effectively throughout the process.

This is important in every mental health claim, but even more so if you are working with a provider that is connected to the disability insurance company. For physicians and dentists filing disability claims, returning to work prematurely can not only be bad for their own mental health, but can also put patients at risk. If you feel that a provider or the disability insurance company are not accurately documenting or considering your limitations, it is a good idea to at least consult with a disability insurance attorney to ensure that your claim is handled fairly.

MetLife and Lyra Health Expand Access to Workforce Mental Health Solutions, Business Wire, June 14, 2023, https://finance.yahoo.com/news/metlife-lyra-health-expand-access-120000267.html?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAAGIragDWvkC4OZlVEAoxh4wEOUspIJauIqPRA2zqzmS2Lr8KXNTggfTilfJ6iUSCGBNnY1YXsMbE9CDPeP6-tGCO7GzGy4BsIl04FE9QxIFlGiObS6yh62gvcdsbl69XomDSPNW5BtJi21BfOurMn6Ty8rlaIHRIF0FmimAj2Y0S

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Defining Occupation:
A Case Study

September 25, 2023

When you file an individual disability insurance claim, one of the first things the insurance company will do is define your occupation, and its job duties. They’ll often look at CDT/CPT codes and financial statements in order to try to determine your job duties. In many instances, insurance companies will seek to define your occupation as broadly as possible.

One such example of this is the case of Minzter v. Providence Life Ins. Co.[1] (Unum). Dr. Minzter, a board-certified ophthalmologist, filed a total disability insurance claim in 2019, based on significant ulnar atrophy of his left hand. According to Dr. Minzter, since 1992 his practice has been focused primarily on pediatric ophthalmology, including ophthalmic surgery (many of his parties suffered from amblyopia or strabismus, which often require surgery). In fact, when he purchased his policy from Unum in 1993, Dr. Minzter indicated that his “occupation” and “exact duties” were “ophthalmic surgeon” on his policy application.

However, in evaluating his claim, Unum deemed Dr. Minzter’s occupation to be that of an ophthalmologist, and stated that his records, including CPT codes, showed that surgery had been only a limited amount of his practice, and pointed to Dr. Minzter’s answers on his Physician Questionnaire that indicated he spend only 5% of his time in the operating room. Unum argued that Dr. Minzter was still performing other duties of an ophthalmologist, except for surgery. Dr. Minzter countered that the practice of eye surgery required a significant amount of time outside of the operating room—including assessing whether patients may need surgery.

Additionally, Unum pointed to the fact that there is no recognized subspecialty of surgery in ophthalmology. Dr. Minzter argued that even if Unum chose to consider him an ophthalmologist rather than an ophthalmic surgeon, he should still be entitled to total disability of because ophthalmology is a surgical specialty.

Because of its evaluation of Dr. Minzter’s occupation, including a review by a vocational rehabilitation consultant, Unum determined that Dr. Minzter was not totally disabled. The Court agreed with Unum, deciding that Dr. Minzter could perform all but one of the substantial and material duties of his occupation, and therefore wasn’t totally disabled. The lawsuit did not address whether Dr. Minzter might be entitled to residual disability benefits, but the Court indicated that it appeared that Dr. Minzter’s claim fell within the purview of that provision.

The takeaway from this case is that insurers (and Courts) will look to what your job duties are at the time of filing a disability claim, not what they were (or what your job title was) at the time you filled out the application for a policy.

If you have questions about whether your occupation is being correctly defined by your insurance company, please feel free to reach out to one of our attorneys directly.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your insurer is not evaluating your claim under the proper standard, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.

[1] Minzter v. Provident Life and Accident Ins. Co., No. CV215595MASJBD, 2023 WL 4108850 (D.N.J. June 21, 2023)

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Statute of Limitations:
A Case Study

September 11, 2023

As we’ve written about before, whether a disability is caused by sickness or injury can be critical in determining the duration of benefits that will be paid out under a disability insurance policy. Another component to this calculation is knowing when to sue, if your insurance company decides to classify a disabling condition as sickness versus injury.

One such example is that of Bennett v. Ohio National Life Assurance Corp[1]. Dr. Mark Bennett, an oral and maxillofacial surgeon, was injured when he was thrown from a horse in 2006, where he sustained injuries to his left shoulder and collarbone. He subsequently underwent surgery; however, he had ongoing numbness and tingling in his left hand. He was able to continue working for a while by changing operating techniques and using different tools. However, despite these changes and treatment (medications and physical therapy), he eventually developed chronic pain in his left hand. He cut down on his patient load, but then had to quit working entirely in 2014.  He filed a claim with Ohio National, stating that he was unable to work as an oral surgeon because of the physical issues he developed as a result of his 2006 accident.

Ohio National approved his benefits, but noted that it would continue to evaluate whether the cause of the disability was due to sickness or injury. In this case, the distinction was important.  Because he was over 55 at the age of filing, he would only be eligible to receive benefits up to age 65 if his condition was caused by sickness. However, if it was caused by injury, he would be eligible for lifetime benefits.

Eventually, on June 8, 2015, Ohio National notified Dr. Bennett that they had determined that his disability was caused by sickness, specifically degenerative disc disease, which was causing compression of nerve roots (leading to the tingling and numbness in his left hand). The letter indicated that benefits would terminate when Dr. Bennett reached age 65.

In September 2018, Dr. Bennett’s benefits stopped. Dr. Bennett sued for breach of contract and breach of the implied covenant of good faith and fair dealing in August 2019. Under the law, Dr. Bennett had four years to file a breach of contact claim and two years to file a claim for breach of implied covenant of good faith and fair dealing. Ohio National argued that the statute of limitations had passed. In other words, they alleged that Dr. Bennett had had waited too long after their initial determination (in 2015) that his disability was caused by sickness to bring a lawsuit. Dr. Bennett argued that the clock did not start running until the date his benefits stopped (in 2018).

The Court reviewed both sides’ arguments and decided in favor of Dr. Bennett. Whether Dr. Bennett is eligible for lifetime benefits remains pending before the Court at the time of this writing.

This case highlights the importance of understanding the terms and requirements of your individual policy.  If you have questions about whether your disabling condition is being handled as an illness versus an injury, please feel free to reach out to one of our attorneys directly.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your insurer is not evaluating your claim under the proper standard, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.

[1] Bennett v. Ohio Nat’l Life Assurance Corp., No. A166049, 2023 WL 4069794 (Cal. Ct. App. June 20, 2023)

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Autoimmune Diseases

August 28, 2023

What are Autoimmune Diseases?

A normal immune system protects the body from disease and infection. With an autoimmune disease, the body’s immune system begins attacking its own organs, tissues, and cells. There are over 100 known autoimmune diseases and they can affect nearly every organ in the body, as well as many tissues. Below are common autoimmune diseases based on the area of the body they affect:

Muscles and Joints:

• Rheumatoid arthritis (RA)
• Psoriatic arthritis
• Lupus

Digestive Tract:

• Celiac disease
• Crohn’s disease
• Ulcerative colitis

Skin:

• Dermatomyositis
• Psoriasis

Endocrine System:

• Hashimoto’s
• Graves’ disease

Nervous System:

• Guillain-Barre syndrome
• Multiple sclerosis (MS)
• CIDP (chronic inflammatory polyneuropathy)

Other:

• Type 1 diabetes
• Myasthenia gravis
• Pernicious anemia

Autoimmune disorders are more common in women than men, and about 1 in 15 people have an autoimmune disease.

What are the Symptoms of Autoimmune Diseases?

Symptoms will vary based on what part of the body is impacted, but common symptoms include pain, fatigue, dizziness, headaches, nausea, malaise, and rashes.

What Causes Autoimmune Diseases?

The exact cause of autoimmune diseases is unknown, but factors include:

• Genetics
• Certain medications
• Having one autoimmune disease already
• Exposure to toxins
• Infections
• Gender (78% of people who have autoimmune diseases are women)
• Obesity
• Smoking

How are Autoimmune Diseases Diagnosed?

Autoimmune disorders often have symptoms that are similar to other diseases, or with each other, so diagnosis can be difficult. Treating providers will generally look at symptoms and health history, and may perform blood tests to look for markers that are associated with certain autoimmune diseases. Tests that may be run include:

• Antinuclear antibody test (ANA)
• Complete blood count (CBC)
• Erythrocyte sedimentation rate (ESR)
• C-reactive protein (CRP)
• Comprehensive metabolic panel
• Urinalysis

What is the Treatment for Autoimmune Diseases?

Autoimmune disorders do not have a cure, so the focus of treatment is on managing symptoms. Types of treatment include:

• Anti-inflammatory medications
• Pain killers
• Plasma injections
• Corticosteroids
• Depression and anxiety medications
• Insulin injections
• Medications to treat rashes
• Intravenous immune globulin
• Immunosuppressive medications
• Physical therapy

Autoimmune diseases can interfere with an individual’s ability to work or carry out daily tasks. If you have been diagnosed with an autoimmune disease and are worried that it may be impeding your ability to continue to safely practice on patients, you should speak with an experienced disability insurance attorney.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described above and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

Sources:

Cleveland Clinic

Mount Sinai

National Institute of Health

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Mental vs. Physical Condition Claims:
A Case Study

August 14, 2023

In some instances, it may not be clear whether symptoms are caused by a physical or mental disability. This distinction can be important because many policies have a mental and nervous limitation, which means that benefits for mental conditions will only be paid out for a limited amount of time (typically 24 months). It’s not surprising that insurance companies may try to argue that a condition is a mental health one, even if treating providers say otherwise, in an attempt to limit the amount of benefits they have to pay out.

One such case is that of Radle v. Unum.[1] In this instance, Radle tripped and hit his head while running, which resulted in dizziness, difficulty focusing, headaches, a “buzzed” feeling, and sensitivity to noise and light.  A few days after the fall, he went to the ER where he was diagnosed with post-concussive syndrome. A few months later, he was admitted to the hospital after another symptomatic episode. Here, he was diagnosed with a conversion disorder, which is defined as a mental condition where a patient shows psychological stress in physical ways.  A few days later, he returned for a second opinion and was again diagnosed with conversion disorder.

However, subsequently, over the course of several years, he engaged in treatment with little to no result (including physical therapy and speech therapy). Because of his progressing symptoms, Radle’s three treating providers re-diagnosed him with delayed post-concussive syndrome. In support of their diagnoses, his providers pointed to the fact that he had an EEG positive for left temporal slowing (which would suggest a brain injury), had testing which showed a visual disability, and had a cyst located near his cerebellum.

Unum’s reviewing physicians, however, disregarded these reports form treating providers and continued to claim that his condition was subject to the mental and nervous limitation of the policy, and as a result, Radle was only entitled to 24 months of benefits.

In response, Radle underwent additional assessments including an independent medical examination (IME) and a Neuropsychological Evaluation, which both concluded that his symptoms were not psychologically based. However, Unum did not accept this evidence, and also claimed that his symptoms did not prevent him from working.

The case remains pending as of this writing, but it illustrates how insurance companies may seek to classify certain conditions as mental health conditions, in order to limit the benefit amount they will have to pay out.  If you are worried about how your insurer is classifying your disabling condition and have questions, please feel free to reach out to one of our attorneys directly.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your insurer is not evaluating your claim under the proper standard, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.

[1] Radle v. Unum Life Ins. Co. of Am., No. 4:21CV1039 HEA, 2023 WL 2474509 (E.D. Mo. Mar. 13, 2023)

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Filing a Claim Based on a Cancer Diagnosis:
A Case Study

August 7, 2023

A cancer diagnosis can lead to the need to file a disability claim, not just for the disease itself but often for the severe side effects that can be experienced during chemotherapy, radiation therapy, and other cancer treatment. But will your insurer recognize this and continue to pay benefits?

You may expect that this would be a straightforward disability claim and, at least at first, it likely will be. However, in our experience, we have noted that some disability insurers may cut off benefits prematurely, in an effort to push cancer survivors back to work despite ongoing medical limitations.

The case of Hardy v. Unum Life Ins. Co.[1] provides an apt example of this. Here, the plaintiff, Mark Hardy was an attorney specializing in defense of malpractice claims. He suffered a fractured pelvis in late October 2016 and later it was discovered that he also had plasmacytoma (a tumor of the plasma cells of bony or soft tissue).

Hardy went on to have surgery to remove the tumor and repair his pelvic bone in November 2016. While he completed five weeks of radiation, it was not successful and he began a course of chemotherapy which left him unable to work a full-time schedule.

According to Hardy’s complaint in this case, the side effects of chemotherapy left him with neuropathy, fatigue, nausea, diarrhea, L pubic ramus destruction, chronic pain, lack of stamina and fatigue-related memory gaps.  While he tried to return to work full-time after his initial period of disability, this became impossible and he began working part-time in February 2019, and also stopped performing the material duties of his specialty occupation (including no longer taking cases to trial). He filed a new LTD claim with Unum on February 11, 2019 and it was initially approved.

In June 2020, Unum requested updated information from Hardy regarding his work status and condition, as well as requesting an attending physician’s statement from his oncologist. On July 13, 2020, Unum recertified Hardy’s disability and let him know that they would not be reviewing his claim for another year. However, just a few weeks later, his case was transferred to a different Unum analyst for additional review. Without notifying Hardy, Unum sent another attending physician’s statement to his oncologist and began a background investigation.

As part of their investigation, Unum sought additional information from his oncologist, sent the file for a medical review, contacted his employer for a job description and had their designated medical officer review the case. They ultimately issued a letter on December 10, 2020 terminating the claim.  Hardy appealed and submitted additional evidence in support of his limitations (including the ongoing support of his oncologist, updated medical records, a vocational analysis, and declarations from other attorneys at his firm). Unum employed an additional medical review and its own vocational analysis. Unum ultimately upheld their termination of the claim and Hardy filed his lawsuit.

While the lawsuit remains pending in court, it demonstrates the difficulty that cancer patients may face when filing disability claims due to a cancer diagnosis and treatment. As in the Hardy case, most often, the primary area of contention relates to the severity and permanency of ongoing complications/side effects after the cancer is in remission. If you have a question on how your insurance company is handling your claim, please feel free to reach out to one of our attorneys directly.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your insurer is not evaluating your claim under the proper standard, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.

[1] Hardy v. Unum Life Ins. Co. of Am., No. 23-CV-563 (JRT/JFD), 2023 WL 4841952 (D. Minn. July 28, 2023)

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Meniere’s Disease

July 31, 2023

What is Meniere’s Disease?

Meniere’s disease is a problem of the inner ear that can lead to vertigo (dizzy spells) and hearing loss. It typically affects only one ear. Some individuals will have single attacks of vertigo separated by long periods of time, while others may experience multiple attacks over a number of days. Sometimes the vertigo is so extreme that an individual will lose their balance and fall (called “drop attacks”).

Meniere’s disease is most common in people in their 40s and 50s. Approximately 615,000 individuals in the U.S. have a current diagnosis of Meniere’s disease, with approximately 45,500 new cases diagnosed each year.

What are the Symptoms of Meniere’s Disease?

Symptoms, can include:

• Regular dizzy spells that usually last 20 minutes to 12 hours, but no more than 24 hours
• Loss of balance
• Hearing loss
• Tinnitus (ringing in the ear)
• Feeling of fullness/pressure in the ear
• Headaches

What Causes Meniere’s Disease?

While the cause of the disease is not known, symptoms may be due to extra fluid (called endolymph) in the ear. Issues that can affect this fluid includes poor fluid drainage, autoimmune disorders, genetics, and/or viral infection.

How is Meniere’s Disease Diagnosed?

In order to meet the diagnostic criteria for Meniere’s disease, an individual must have had two or more vertigo attacks, hearing loss, and tinnitus or a feeling of pressure in the ear. Tests performed by a healthcare provider will include a hearing assessment, a balance assessment, and tests that study how the inner ear is working. Often other tests, including labs and imaging, will be used to rule out other conditions.

What is the Treatment for Meniere’s Disease?

There is no cure for Meniere’s disease and no treatment for any resulting permanent hearing loss. Treatments are instead aimed at lessening vertigo attacks and preventing hearing loss from getting worse.

Treatments include:

• Motion sickness medications
• Anti-nausea medications
• Diuretics
• Lifestyle changes including a low-salt diet, consuming less caffeine and managing stress
• Vestibular rehabilitation
• Hearing aids
• Middle ear injections
• Pressure pulse treatment
• Endolymphatic sac surgery (relieves pressure around the endolymphatic sac, which can improve fluid levels)
• Labyrinthectomy (parts of the ear that cause vertigo are removed, which causes complete hearing loss in the affected ear)
• Vestibular nerve section (the vestibular nerve is cut to block information about movement for getting to the brain, to improve vertigo)

Meniere’s disease can interfere with an individual’s ability to work or carry out daily tasks. If you have been diagnosed with Meniere’s disease and are worried that it may be impeding your ability to continue to safely practice on patients, you should speak with an experienced disability insurance attorney.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described above and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

Sources:

Mayo Clinic

Johns Hopkins

Cleveland Clinic

National Institute of Health

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Injury versus Sickness:
A Case Study

July 17, 2023

While it might seem like it should be easy to determine whether a disabling condition is caused by an injury or sickness, this is not always the case, especially when it comes to repetitive stress injuries.  Under some policies, the difference can be drastic in terms of how long benefits are paid.

One example is the case of Stein v. Paul Revere Life Ins. Co[1]. Dr. Stein was a specialist in interventional radiology who was diagnosed with and eventually unable to work due to spinal stenosis, lumbar osteoarthritis, lumbar spondylosis, and degenerative spondylolisthesis.  Whether or not his condition was an injury or sickness was important in this case because he was eligible to receive full lifetime benefits if his condition was caused by injury (but only a portion of his benefits for life if it was due to sickness).

While he initially filled out his application for benefits, Dr. Stein filled out the sickness portion of the form, and indicated that his occupation exacerbated his condition. However, later, Dr. Stein sought to change this classification of his disability from sickness to injury, claiming that his disabling conditions were actually the result of repetitive stress injuries (caused as a result of having to wear a heavy lead apron as part of his occupation). In support of this claim, Dr. Stein submitted statements from his treating provider and medical journal articles that showed there was evidence of a relationship between wearing leaded aprons and spinal problems.

Paul Revere had three physicians review Dr. Stein’s records, and all concluded that Dr. Stein’s conditions were due to sickness, or at the very least “cannot be ascribed, beyond reasonable doubt, to repetitive stress injury more than any of the many other proposed causes of disc degeneration.” The third reviewing doctor also indicated that the medical file did not indicate that there had ever been an accident. Dr. Stein countered that Paul Revere was misinterpreting the term accident, and failing to consider repetitive stress injuries.

The Court found that Dr. Stein’s arguments were persuasive. They noted that there was not an expectation that he could have known that he was likely to become injured (thus meeting the “accidental bodily injury” requirement of his policy), and that he was suffering from a physical condition resulting from repetitive stress injuries. In finding for Dr. Stein, the Court concluded that he was entitled to a reclassification of his total disability as due to an “injury” and thus eligible for full lifetime benefits.

However, here, the Court did not award Dr. Stein attorney fees, explaining that Dr. Stein himself had originally applied to receive benefits under the “sickness” category and that Paul Revere’s interpretation of its policy language was “reasonable.”

This case highlights the importance of understanding the terms and requirements of your individual policy.  If you have questions on how your policy works or how your claim is being administered, please feel free to reach out to one of our attorneys directly.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your insurer is not evaluating your claim under the proper standard, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.

[1] Stein v. Paul Revere Life Ins., Co., No. CV 21-3546, 2023 WL 2539004 (E.D. Pa. Mar. 16, 2023)

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Complex Regional Pain Syndrome

June 19, 2023

What is Complex Regional Pain Syndrome?

Complex regional pain syndrome (CRPS) isn’t clearly understood, but it is a form of chronic pain that usually affects an arm or a leg. CRPS usually develops after an injury, surgery, stroke or heart attack. The pain is often prolonged and out of proportion to the severity of the initial injury. CRPS can either be acute (recent, short-term) or chronic (lasting greater than six months).

CRPS is divided into two groups.  The first, also called sympathetic dystrophy, develops without known nerve damage. The second, also called causalgia, occurs as a result of specific nerve damage. About 90% of cases are type 1.

While most cases of CRPS are mild and an individual recovers in a few months to a few years as the injured nerve regrows, symptoms can persist and long-term disability may result. If untreated, the disease can progress and atrophy (tissue wasting) and contracture (muscle tightening) can develop.

What are the Symptoms of Complex Regional Pain Syndrome?

Symptoms, can include:

• Continuous burning or throbbing pain, typically in an arm, leg, hand or foot (in some instances “mirror pain” may develop in a matching location on the opposite limb)
• Increased sensitivity to painful stimuli
• Feeling pain from stimuli that are not usually painful
• Sensitivity to touch or cold
• Numbness
• Joint stiffness, swelling and damage
• Muscle spasms, weakness, and tremors
• Decreased mobility in affected body part
• Swelling
• Changes in skin temperature, color, and texture
• Changes in hair and nail growth

Having CRPS is also associated with increased anxiety, depression and stress.

What Causes Complex Regional Pain Syndrome?

The exact cause of CRPS isn’t clearly understood, but it is thought to be caused by an injury to or a difference in the peripheral and central nervous system. In many causes, CRPS results after a trauma to an arm or a leg. The most common actions/activities that lead to CRPS include fractures, surgery, strains/sprains, limb immobilization (e.g., from being in cast), and lesser injuries such as burns or cuts.

Other influencing factors include poor circulation, poor nerve health, immune system involvement (for example, some individuals with CRPS have abnormal antibodies), and genetics.

How is Complex Regional Pain Syndrome Diagnosed?

There is no one test for CRPS, but the following are used in determining whether an individual may have CRPS:

• Physical exam
• Nerve conduction studies
• Ultrasound
• MRI
• Bone scans
• X-rays
• Sweat production tests

What is the Treatment for Complex Regional Pain Syndrome?

Treatments include:

• Medications (pain relievers, antidepressants and anticonvulsants, corticosteroids, bone-loss medications, synthetic nerve-block medications, intravenous ketamine, blood pressure lowering medications, topical analgesics)
• Heat therapy
• Physical or occupational therapy
• Biofeedback
• Acupuncture
• Mirror therapy
• TENS
• Spinal cord stimulation
• Intrathecal drug pumps

Outcomes for CRPS can vary widely, and early diagnosis and treatment is key. CRPS usually improves over time and goes into remission in most people; however, severe or prolonged cases can occur, and it recurs in about 10-30% of individuals.

Complex Regional Pain Syndrome can interfere with an individual’s ability to work or carry out daily tasks. If you have been diagnosed with CRPS and are worried that it may be impeding your ability to continue to safely practice on patients, you should speak with an experienced disability insurance attorney.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described above and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

Sources:

Mayo Clinic

National Institute of Neurological Disorders and Stroke

John Hopkins

Cleveland Clinic

Stanford

Occupation at Time of Disability:
A Case Study

June 5, 2023

Often, a definition of total disability includes a phrase along the lines of you are considered Totally Disabled “you are not able to perform all or the substantial and material duties of your regular occupation at the start of your Total Disability.” While this may seem straightforward, we’ve seen conflicts arise when it comes to defining what an insured’s regular occupation was at the start of a disability.

One such example is the case of Johnson v. Ohio National.[1]  Dr. Johnson was an OB/GYN from 1993 through May 2007, with several different employers.  However, from May to October 2007, he took time off and was subsequently not able to find work in the OB/GYN field, although he was actively looking for it.  From October 2007 through March 2008, he worked on a temporary basis at a clinic, filling in for other doctors as needed. He also worked part-time as a physician at an Urgent Care clinic (where he did no OB/GYN-related duties).

In June of 2008, Dr. Johnson saw an internal medicine doctor for joint pain, swelling and stiffness in his hands, along with a rash. Lab tests revealed significant inflammation of the hands.  Dr. Johnson was referred to and saw a rheumatologist on November 14, 2008, where he was diagnosed as having psoriatic arthritis. On December 26, 2008 he submitted a claim with Ohio National for total disability.  Although Ohio National agreed on the date of disability (June 2008) and that psoriatic arthritis prevented Dr. Johnson from practicing as an OB/GYN, they claimed his occupation at the time of his disability was that of an urgent care doctor—and that he was still able to do the material and substantial job duties of an urgent care physician.

The Courts agreed with Ohio National, finding that at the time of his disability, Dr. Johnson was working as an urgent care physician, regardless of the fact that he was a Board-certified OB/GYN and had been doing that for the majority of his career.

We’ve encountered dentists and physicians who inadvertently change their occupation by starting to work in another position or role, or otherwise modify their job duties, often as a way to accommodate a disability.  Since regular occupation is often defined along the lines of “the occupation (or occupations if more than one) in which you are regularly engaged at the time you become Totally Disabled,” insurance companies will typically ask for CPT or CDT codes to identify the specific job duties you are doing at the time your disability started. In some instances, this might allow an insurance company to claim you are not working in your specialty and try to claim you are doing the very broadest job possible (thus making it easier to say you are still able to work).

This case highlights the importance of understanding the terms and requirements of your individual policy when it comes to how total disability is defined.  If you are worried about how your insurer is classifying your occupation and have questions, please feel free to reach out to one of our attorneys directly.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your insurer is not evaluating your claim under the proper standard, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.

[1] Johnson v. Ohio National Life Assurance Co., No. WD-12-029, 2014 WL 201691 (Ohio Ct. App. Jan. 17, 2014).

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Postural Orthostatic Tachycardia Syndrome
(POTS)

May 8, 2023

What is POTS?

Postural orthostatic tachycardia syndrome (POTS) is a group of disorders that have orthostatic intolerance (OI) as their primary symptom. It’s a condition that causes a number of symptoms when an individual transitions from laying down to standing up.

The primary symptom of OI is lightheadedness or fainting.  With POTS, this is also accompanied by a rapid increase in heartbeat of more than 30 beats per minute or a heart rate that tops 120 beats per minute, within 10 minutes of standing. Laying down relieves the faintness/lightheadedness.

While normally the body’s automatic nervous system balances heart rate and blood pressure, someone with POTS can’t coordinate the balancing act of blood vessel constriction and heart rate response; therefore, the body can’t keep blood pressure stable.

POTS affects about 1 to 3 million people in the United States (although experts believe this number may have risen since COVID-19), with the majority being women between 15 and 50 years old. Those who have had a significant illness, serious infections, are pregnant, have physical trauma or surgery are at a higher risk of developing POTS.

POTS can be further divided into sub-types:

Neuropathic POTS: when peripheral enervation (loss of nerve supply) leads to poor blood vessel muscles

Hyperadrenergic POTS: when the sympathetic nervous system is overactive

Hypovolemic POTS: reduced blood volume

One of the biggest risks of POTS is falling and getting injured.  In some, POTS symptoms will resolve, but they may return.  About 25% of POTS patients are disabled and unable to work.

What are the Symptoms of POTS?

Thy symptoms of PTOS vary by individual, and happen immediately or within a few minutes after sitting or standing up. Symptoms can include:

• Dizziness
• Fainting
• Brain fog
• Racing heart rate or palpitations
• Chest pain
• Fatigue
• Nervousness or anxiety
• Shakiness
• Excessive sweating
• Shortness of breath
• Headaches
• Nausea or vomiting
• Bloating
• Purple discoloration of hands and feet, if they are lower than heart level, and a pale face
• Disrupted sleep

Several conditions can worsen POTS symptoms, including:

• Being in warm environments
• Standing frequently
• Being sick
• Menstruation
• Strenuous exercise

What Causes POTS?

Its not entirely clear what causes POTS, but growing evidence suggests that POTS may be an autoimmune disease.

How is POTS diagnosed?

A tilt table test is one of the primary methods a physician will use to diagnose POTS.  It measures heart rate and blood pressure during changes to posture and position. Other tests that may help confirm POTS and/or rule out other conditions include blood tests, QSART (a test that measures the nerves that control sweating), automatic breathing tests, tuberculin skin tests, skin nerve biopsy, echocardiogram, and blood volume with hemodynamic studies.

What is the Treatment for POTS?

There is no cure for POTS, but there are recommendations that can help manage the symptoms of POTS, including:

• Engaging in exercise and physical activity
• Managing diet and nutrition (for example, for hypovolemic POTS, a dietician may recommend increasing salt and fluid intake)
• Certain medications including those that treat tachycardia, increase salt retention and blood volume) and/or cause vasoconstriction.

POTS can interfere with an individual’s ability to work or carry out daily tasks. If you have been diagnosed with POTS and are worried that it may be impeding your ability to continue to safely practice on patients, you should speak with an experienced disability insurance attorney.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional. If you are experiencing any of the symptoms described above and have yet to consult with a doctor, do not use this resource to self-diagnose. Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.

Sources:

Cleveland Clinic

National Institute of Neurological Disorders and Stroke

John Hopkins Medicine

Dysautonomia International

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Do I Have to Attend an IME in Person?:
A Case Study

April 24, 2023

Under many disability insurance policies, insurers can require an insured to attend an independent medical examination (IME) in order to remain eligible for benefits. While some policies may explicitly state that an IME must be in person, other are silent on this. So, what happens if you are worried about attending an in-person IME due to potential health risks and/or the COVID-19 pandemic?

One example of this scenario is the case of Masevice v. Life Ins. Co. of North America[1]. Ms. Rebecca Masevice was a marketing manager who became unable to work due to migraine headaches, cluster headaches and POTS (postural orthostatic tachycardia syndrome), dizziness, fatigue, shortness of breath and brain fog. She filed a disability claim with her insurer, Life Insurance Company of North America (LINA).

LINA requested that Masevice undergo an IME, and scheduled one.  Masevice requested that this IME be held via “telemed.”  LINA denied this request and re-scheduled the IME multiple times and ultimately denied her claim. Masevice pointed to the “extraordinary circumstances of the COVID-19 pandemic” and disputed that she didn’t cooperate with the scheduling of an IME.  On appeal, Masevice provided updated records, letters/reports from her treating provider, an FCE, a list of medications, and a vocational report.  In their decision noted that “Plaintiff’s concerns about attending the IME in person were valid, given her symptoms and her compromised immune system.”

However, the Court further ruled that more fact-finding was needed in order to determine whether Masevice was eligible for benefits. The Court remanded the case, indicating that Masevice be given the opportunity to submit additional, current medical evidence and that LINA may require that Masevice undergo an in-person IME “now that the COVID-19 crisis has been alleviated.”

This case highlights the importance of understanding the terms and requirements of your individual policy.  If you are facing an IME and have questions, please feel free to reach out to one of our attorneys directly.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your insurer is not evaluating your claim under the proper standard, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.

[1] Masevice v. Life Ins. Co. of North America, Case No. 1:22CV223, 2023 WL 2534042 (N.D. Ohio March 16, 2023).

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