If my doctor says I can’t work, doesn’t that imply I have functional restrictions?

Question: I have degenerative disc disease and a herniated disc, have had spinal fusion surgery, and I still am not able to return to my job. I was hoping that the insurance company would approve me for long-term disability benefits (following the expiration of my short-term benefits). However, the insurance company said I don’t have any continuing restrictions even though my doctor says that I should not return to work yet. I called the insurance company and they said the medical records submitted by my doctor’s office don’t show what restrictions I have. Shouldn’t the off-work order be enough?! 

Answer: Generally a long-term disability insurance company wants objective, comprehensive medical evidence that there are specific functional restrictions that prevent you from returning to work. A doctor’s note that you can’t return to work until your next evaluation, or that you are fully disabled and should not return to work, is not going to cut it. Insurance companies want to know the following:

  • how long you can stand, walk, or sit
  • how much weight you can lift, push, or pull
  • whether you can reach overhead, bend, or stoop
  • whether you can handle small object with your fingers or type
  • how frequently you need to take breaks, and
  • how much time you need to take off work for sick days or hospitalizations.

If your doctor can provide this information and it shows your functional limitations (restrictions) are great enough to keep you from working, you should be able to get approved for long-term disability (LTD). If you apply for Social Security disability insurance (SSDI), the Social Security Administration will want this information as well. The best way to gather this information is to have your doctor fill out a detailed functional capacity report about what you can and cannot do.

Don’t rely on the insurance company to send forms to your doctor to fill out; insurance paperwork isn’t likely to solicit answers to questions in your favor, and it’s not likely to be as comprehensive as a functional capacity form. Plus, you won’t know whether your doctor filled out the forms or instead just sent a short note with an unsupported opinion on your disability.

Nolo has a residual functional capacity form you can give to your doctor to document your restrictions for both your LTD claim and your SSDI claim. The form also asks for clinical findings and test results that back up the doctor’s opinion on your restrictions. Tying this evidence to the doctor’s opinion is key to getting an approval.

Explain to your doctor that the insurance company needs details, hand him or her the form to fill out, and ask the doctor to send you a copy of the filled out form. That will give you the evidence you need.

If you’ve been officially denied, however, you should talk to a disability lawyer before filing an appeal. A lawyer can help you “stack the administrative record” with evidence so that, if you have to file a federal lawsuit, the court will be able to consider all of your evidence (a federal court can’t consider any evidence that wasn’t brought up in an appeal to the insurance company).

If you’re considering applying for SSDI, you may also find this Nolo article on getting disability benefits for back problems helpful.