Multiple sclerosis is a serious, well-documented neurological disease. Insurers rarely dispute the diagnosis. MS claims are denied for a different reason: the symptoms that keep many people with MS from working, especially fatigue and cognitive problems, do not show up on an MRI or in a 30-minute exam.
Example: a treating neurologist concludes that a patient’s MS causes disabling fatigue and cognitive impairment. The insurer’s reviewing doctor reads the same records and says the patient can work full time at a desk. That conflict is at the center of many MS claims, and the evidence you build decides who wins it.
Why insurers push back on MS claims
- A normal exam between relapses. In relapsing-remitting MS, a neurological exam can look close to normal between flare-ups. The insurer reads that as recovery.
- “Stable” MRIs. No new lesions is good medical news, but the insurer may treat it as proof of improvement, even though symptoms persist.
- Fatigue is hard to see. MS fatigue is one of the most common and disabling symptoms, but it is reported by the patient. Some policies limit benefits for conditions based mainly on self-reported symptoms, and insurers may try to apply that clause.
- Cognitive problems go unmeasured. Slowed processing, memory problems, and trouble multitasking are common in MS, but often never formally tested.
- You look fine. Many people with MS look healthy on the days anyone sees them.
The evidence that matters
Objective neurological evidence. MRI findings, the neurologist’s exam findings over time, and any disability rating scale your neurologist uses establish the disease and its course. Records of each relapse, its symptoms, and treatment show the pattern.
Neuropsychological testing. If you have trouble with memory, concentration, or processing speed, formal testing by a neuropsychologist can turn a “subjective” complaint into measured results. It is often the strongest evidence in an MS claim for a professional or office worker.
Fatigue documentation. Your neurologist should record fatigue at every visit: how often you must rest, for how long, and how it affects your day. Standardized fatigue questionnaires in the records help. So does a daily diary of your activity and rest.
Heat sensitivity and other symptoms. Many people with MS get worse in heat. Vision problems, balance problems, weakness, numbness, spasticity, and bladder urgency all affect work, and each should be documented with its effect on function.
Treatment history. Disease-modifying therapy, steroid treatment for relapses, and medications for fatigue, pain, or spasticity, with their side effects, show the seriousness of the disease and its burden.
Limits your neurologist should document
- how long you can work before you must rest, and how long you need to rest,
- how many days a month you would likely miss because of relapses, fatigue, or appointments,
- limits on concentration, memory, and pace,
- limits on walking, standing, balance, and use of your hands,
- effects of heat, and of medication side effects, and
- whether your symptoms are unpredictable from day to day.
Unpredictability matters. An employee who has good days and bad days without warning may be unable to sustain work even if the good days look normal. The records should say so.
Policy provisions to watch
- Own vs. any occupation. A surgeon or air traffic controller with mild cognitive slowing may be disabled from her own occupation long before she is disabled from all work. Know when your definition changes. More: Own occupation vs. any occupation.
- Self-reported symptom limitations. MS is a neurological disease confirmed by imaging and clinical findings. If an insurer tries to apply a self-reported-symptoms limitation, read the clause carefully; it may not fit.
- Mental health limitations. Depression is common with MS. If depression is also documented, make sure the records show that the MS itself independently limits you, so the insurer cannot recast your claim as a mental health claim. More: The 24-month mental health limitation.
When the insurer’s doctor disagrees
If a reviewing or examining doctor says you can work, get the report and ask your neurologist to answer it: what evidence it overlooked, why a single normal exam does not reflect the course of the disease, and why fatigue and cognitive problems are consistent with your MS. If cognitive problems are disputed and you have not been tested, consider neuropsychological testing before your appeal. More: What to expect at an IME.
What to do now
- Read your policy’s definition of disability and any limitations clauses.
- Tell your neurologist about fatigue and cognitive problems at every visit, with specifics.
- Ask about neuropsychological testing if thinking problems affect your work.
- Keep a symptom and fatigue diary.
- Ask your neurologist for a functional statement before you file, before your 24-month review, or before an appeal.
Denied or cut off with MS? Call 770-351-0801 or request a free case evaluation.
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