You have severe back pain. Maybe you have had surgery, injections, and physical therapy, or your doctors have told you there is nothing more they can do. You cannot sit for long. Standing and walking hurt. You lie down several times a day. Your doctor agrees you cannot work, and your long-term disability insurer denies your claim anyway.
Insurers do not pay just because you have a serious diagnosis or an abnormal MRI. They want evidence showing exactly how your back condition keeps you from working. Here are five ways to build that evidence.
1. Know what your insurer is actually deciding
The question is not whether you have back pain. It is whether your condition keeps you from doing the duties your policy describes. Many policies start with an own-occupation test and switch to an any-occupation test, often after 24 months.
Example: a 55-year-old construction worker with lumbar spinal stenosis cannot lift, bend, climb, or stand for a shift. An accountant with the same condition faces a harder claim, because the insurer will call accounting sedentary work. Same spine, different outcome. Get your policy and find the definition that applies to you. More: Own occupation vs. any occupation.
2. Get objective evidence, and connect it to your symptoms
Testing helps show that a spinal condition is real and how severe it is:
- MRI or CT can show herniated discs, stenosis, nerve root compression, and other structural problems.
- X-rays can show degenerative changes or instability.
- EMG and nerve conduction studies can document nerve damage.
- Physical exam findings such as weakness, sensory loss, reduced reflexes, positive straight-leg raising, or an abnormal gait add support.
- Surgical records show what was found and what was done.
The tests must connect to your symptoms. An MRI showing severe stenosis at L4-L5, together with records of radiating leg pain, weakness, and trouble walking, is much stronger than the MRI report alone.
Not everyone with disabling back pain has dramatic imaging or abnormal neurological findings. A normal test does not prove you can work, but it means the rest of your evidence has to carry more weight.
3. Make sure your doctor documents specific limits
This may be the most important part of a back pain claim. Compare:
“My patient has chronic lumbar pain and is unable to work.”
“My patient’s lumbar pain increases after about 20 to 30 minutes of sitting. He needs frequent position changes and cannot tolerate prolonged sitting or standing. His symptoms keep him from sustaining activity through a normal workday.”
The second gives the insurer what it needs. Your doctor should address how long you can sit, stand, and walk; lifting, bending, twisting, and reaching; whether you must alternate positions or lie down, how often and how long; and whether pain or medication affects concentration or requires unscheduled breaks. And the doctor should explain the medical basis for each limit.
It helps to give your doctor a short written description of your limits before your visit: how long you can sit before you have to move, how long you can stand or walk, what makes the pain worse, how often you lie down, how often you have flare-ups, your medication side effects, and how long you need to recover after activity. The goal is accurate documentation, not exaggeration. I am not asking any doctor to sign off on limits the medical evidence does not support. More: Why your doctor must describe limitations.
4. Show why you cannot sustain a regular schedule
Insurers often concede the diagnosis and argue you can do a desk job. But sedentary work means sitting for long stretches and concentrating. Many people with serious spine problems cannot stay in one position; they need to change positions or recline, medication affects their alertness, and flare-ups affect attendance.
Example: a claimant can sit at a computer for 30 minutes. Then he has to stand, stretch, and lie down for 20 minutes, and he repeats that cycle all day. The insurer focuses on the fact that he can sit and use a computer. The real question is whether he can keep up the pace, attendance, and output the job requires, day after day.
Keep a symptom diary of how long you can sit, flare-ups, rest periods, and how symptoms affect your day. More: My insurer says I can do sedentary work.
5. Show that you have pursued treatment
Your treatment history shows that your symptoms persist despite real efforts. Physical therapy, medications, injections, specialist visits, and surgery all belong in the record. Example: a claimant who has had physical therapy, epidural steroid injections, medication management, and two lumbar surgeries, and still cannot sit for long, has a treatment history that tells the story.
Gaps in treatment invite questions. But limited treatment does not mean a mild condition. Some patients are not surgical candidates, some have exhausted reasonable options, and cost, risk, and side effects can all explain treatment choices. Make sure your doctors document why a treatment did not work, is not available, or is not recommended.
Be ready for the insurer’s reviews
The insurer may send you to an independent medical exam or have a doctor review your records. If that doctor says you can sit six hours a day and your treating doctor says three hours in total, a vocational consultant may build a list of sedentary jobs on the six-hour number. If the medical assumption is wrong, the vocational report falls with it. Your treating doctor should respond to the insurer’s review point by point. More: What to expect at an IME and 5 reasons the vocational report may be wrong.
A note for claimants over 50
Social Security’s grid rules can support a disability finding for older claimants who cannot do certain levels of work. LTD policies generally do not use those rules. A 55-year-old construction worker may win SSDI and still face an LTD denial if the insurer decides he can do suitable sedentary work. More: Approved for SSDI: what happens to my LTD claim?
Three mistakes to avoid
- Assuming your MRI proves you are disabled. It proves a condition, not your limits.
- Telling your doctor about pain but not about work. Say you cannot sit long enough to finish a workday, if that is true.
- Describing your activities inaccurately. If you say you cannot lift anything and surveillance shows you carrying groceries, your credibility suffers. Say what you can do, how often, and what happens afterward.
Denied or cut off for a back condition? Call 770-351-0801 or request a free case evaluation.
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