Why Your Doctor Must Describe Limitations, Not Just Diagnoses, for LTD

Here is the kind of sentence that shows up in LTD denial letters, in one form or another: “While the medical records confirm your diagnosis, they do not establish functional limitations that would prevent you from performing your occupation.”

Read it carefully. The insurance company is not saying you are healthy. It agrees you have degenerative disc disease, or multiple sclerosis, or heart failure. It is saying your file does not show what that condition keeps you from doing. That gap is the most common reason long-term disability claims fail, and it is the one you can do the most about before you file.

A diagnosis answers the wrong question

Your LTD policy does not pay for a diagnosis. It pays if you cannot do the duties of your occupation, or of any suitable occupation, depending on your policy. So the question the insurer asks is about function: how long can you sit, stand, and walk? How much can you lift? Can you concentrate for a full day? Can you show up every day?

Two people with the same MRI can have very different limits. The insurance company knows that, and so will its reviewing doctor. That is why an insurer’s examining or reviewing doctor can agree with your diagnosis and still conclude that you can do sedentary work. The diagnosis is often not what is in dispute. The real dispute is whether you can sustain full-time work.

Why medical records often fall short

Doctors write records to treat you, not to prove a disability claim. That creates predictable problems:

“Stable” and “doing well.” Your doctor writes “stable” because you are no worse than last visit, or “doing well” because the new medication helped a little. The insurer reads those words as proof you can work.
Normal findings, no explanation. Notes record normal strength, normal gait, and no neurological deficits, but never explain why you still cannot sit for more than 20 minutes.
Symptoms without function. “Patient reports fatigue” tells the insurer nothing about how many hours a day you can work.
A one-line “disabled” note. A note that says “patient is disabled” or “unable to work” with no explanation carries much less weight than a detailed description of your restrictions.
Gaps in treatment. Months without a visit look like months without a problem.

What your doctor should document

The most useful evidence is a statement from your treating physician that describes your limits in numbers and explains the medical reason for each one. Depending on your condition, that includes:

Physical limits

how long you can sit at one time, and in total in an 8-hour day,
how long you can stand and walk, at one time and in total,
whether you need to change positions, lie down, or recline, how often, and for how long,
how much you can lift and carry, and how often,
limits on reaching, handling, fine finger use, bending, or stooping.

Mental and endurance limits

ability to concentrate, and for how long before you need a break,
effects of pain, fatigue, and poor sleep on attention and pace,
medication side effects such as drowsiness, dizziness, or slowed thinking,
for psychiatric conditions, problems with memory, decision-making, dealing with people, and handling stress.

Reliability

how many unscheduled breaks you would need in a workday,
how many days a month you would likely miss because of bad days, flare-ups, or appointments.

Compare these two statements:

“Patient has lumbar degenerative disc disease and is unable to work.”

“She can sit for about 20 minutes at a time, for a total of about 2 hours in an 8-hour day, before increased back and leg pain forces her to stand or lie down. She must lie down for 30 to 60 minutes twice a day. Her pain and medication side effects will cause her to miss more than three days of work a month. These limits are consistent with her MRI findings of multilevel disc disease with nerve root involvement and with her treatment history.”

The first is a conclusion. The second is evidence.

Objective support helps

Insurers lean heavily on objective findings. Where they exist, your records should connect your limits to them: imaging, nerve conduction studies, cardiac testing, lab results, neuropsychological testing for cognitive problems, or a functional capacity evaluation. Many conditions, such as fibromyalgia, migraine, and chronic fatigue, have few objective markers. For those, consistent treatment over time, detailed symptom descriptions, and your doctor’s explanation of why your symptoms are credible become even more important.

How to ask your doctor

Most doctors want to help but do not know what an insurance company needs. A few practical points:

Tell your doctor about your limits at every visit, in specifics. “I can stand about 10 minutes before I have to sit down” is far more useful than “my back hurts.”
Ask for a functional statement, not a disability letter. We can give your doctor a questionnaire that asks exactly the questions above, which makes it easier for a busy physician to answer.
Be accurate. I am not asking any doctor to stretch the truth. Do not exaggerate your limits or downplay what you can do. An insurer that finds a mismatch, on surveillance, social media, or in your own forms, will use it against everything else in your file.
Keep your treatment regular. Follow your treatment plan, keep your appointments, and tell your doctor about side effects and bad days.

Your treating doctor’s opinion does not win automatically

In ERISA cases, the insurance company is not required to give your treating physician’s opinion special weight. The Supreme Court said so in Black & Decker Disability Plan v. Nord (2003). But the Court also said an insurer may not arbitrarily refuse to credit reliable evidence, including a treating physician’s opinion. A detailed, well-supported opinion is much harder to ignore than a one-line note, and it gives you something concrete to point to if the insurer’s own doctor disagrees. More: Top 5 reasons LTD claims are denied.

What to do now

Read your policy’s definition of disability so you know which question your doctor needs to answer. More: Own occupation vs. any occupation.
Keep a simple symptom diary: bad days, how long you can sit or stand, naps, and medication side effects.
Ask your treating physician for a functional statement before you file, or before your 24-month review.
If the insurer’s doctor disagrees, get the report from your claim file and ask your doctor to respond point by point.

Why Your Doctor Must Describe Limitations, Not Just Diagnoses