You work at a desk job and your disability prevents you from performing your occupational duties. It may have happened suddenly (like a car accident) or maybe the result of a gradual decline (like carpal tunnel syndrome or degenerative disc disease). You filed a disability claim and may have been approved for Short-Term Disability (STD) benefits, but your Long-Term Disability (LTD) claim was denied…the insurance company sent you a denial letter because, they say, “your job is sedentary.”
Now what?
First, understand that what the insurance company means by a “sedentary job” is probably very different from what you think of when you think about your job. In short, the insurance company focuses on the “sedentary” part and often ignores the “job” part. They assume that if you can sit for 6-8 hours a day, you can work a full-time job. But in real life (where you live) it’s rarely that simple.
Second, know your options. You probably have the right to appeal the decision (everyone gets at least one appeal). But you have to be smart about it. Outrage will get you nowhere. Neither will be pleading with the insurance company to be reasonable. You need to “connect the dots” for the insurance company and show them why your medical records and your job description leave you no room to work.
If you do nothing else, at least have an experienced ERISA attorney review your denial letter and give you their thoughts. At BenGlassLaw, we do this for free. If we think we can help further with the appeal, we’ll tell you how to work with us, but there is never any obligation or cost to hear our thoughts on the denial letter.
Let’s look more closely at what it means to be denied because “your job is sedentary,” and what steps you can take to make your appeal as strong as possible.
What is Considered Sedentary Work?
Insurance companies use “industry-standard” definitions to determine whether your job is sedentary, light duty, medium or heavy. (That “light duty” category can be tricky, because to most people, including maybe your doctor, being on “light duty” means doing less than you normally would. For the insurance company, though, having the capacity for “light duty” still means you can work full-time.)
“Sedentary” jobs require workers to be able to lift a maximum of ten pounds for one-third of the workday, lift very light objects one-third or two-thirds of the workday, sit most of the workday, and/or occasionally walk and stand.
Obviously, it can be harder to prove that you are physically unable to work at a sedentary job than it is to show you are disabled from a heavy-duty job. If your disability prevents you from working, though, and your doctor will explain why, you have a valid claim and have every right to collect disability benefits.
What makes someone unable to work a sedentary job? Well, restrictions on sitting, for one. If you cannot spend a day “mostly sitting,” you cannot work a sedentary job. The key to making that claim is to have your doctor document your sitting restrictions and back them up with test and exam results. A claim based on, “I am in too much pain to sit all day,” is not strong. A claim that says, “My patient is unable to sit longer than 30-60 minutes at a time for a total of four hours in a day due to severe back pain as confirmed by (x-ray/MRI/physical exam results),” is far more likely to be approved.
If your restriction is not related to sitting but has more to do with stamina or reliability (say, if you are frequently absent due to severe migraine headaches), again, have your doctor document that. Explain what your treatment has been, what your prognosis is, and what your restrictions and limitations are. Keep a headache journal and share that with your doctor to show how often your headaches are disabling.
How Do Insurance Companies Decide Whether You Can Work a Sedentary Job?
You are confident that your disability claim should have been approved and feel as though the insurance company made a mistake. The big question that probably remains on your mind is, why did they deny my claim?
When looking at your claim, insurance companies will make it seem like your job requires nothing more than sitting in a chair. They will not focus on the pain, cognitive, and other limitations that prevent you from actually getting any work done. But there are ways to fight this. First, you need to understand what resources they are using.
You may see in your denial letter a reference to the Dictionary of Occupational Titles (DOT). Insurance companies use the DOT to compare your job with your functional abilities, or (depending on how long you have been receiving benefits) to compare your functional abilities with the requirements of any sedentary job that you have the training, education and experience to perform.
The DOT is a publication by the United States Department of Labor which helped employers, government officials, and workforce development professionals define over 13,000 different types of work from 1938 to 1999. The DOT has since been considered out of date and has been replaced by an online database, O*NET.
Although it is considered out of date, insurance companies are still allowed to use the DOT as a reference when reviewing disability claims. Crazy, right? Considering that technology and job descriptions have vastly changed since the DOT was last updated in 1991 (some jobs in the DOT have not been updated since 1978), the use of the DOT can become quite a problem for your disability claim. The job you do today may have the same title as a job from the DOT, but the work required is dramatically different (for example, “order takers” used to use pencil and paper. Today, you need to be computer literate to be able to process orders).
How to Appeal a Long-Term Disability Claim Denial for a Sedentary Job?
First, understand what the insurance company is saying about your job. Are they right? If not, you need to make sure they have an accurate job description. Work with HR to get one or write one yourself and have HR approve it. Do you have past performance reviews? Often those will talk about what job duties are required for your position.
Next, understand your policy. How long does it protect you if you are unable to do your own job? When does the definition of “disabled” switch from being unable to do your job to being unable to do any job, even a sedentary job? Make sure you are using the correct standard in your appeal. It does not help to prove you are unable to do your job if the standard has changed and you need to show you are unable to do any job to be eligible for benefits.
Finally, put together an appeal that connects all the dots. Work with your doctor to explain in detail why you cannot work and what evidence there is to support your claim. We almost always recommend that you work with an experienced disability attorney for this step, for two reasons: you need to know how to really connect the dots and what to avoid, and you need to add any legal arguments about what the insurance company did wrong to violate ERISA requirements. That last part is important because if your appeal is denied and you have to file a lawsuit, no new evidence is allowed at that point. If you didn’t make an argument in the appeal, you can’t add it in the lawsuit. That’s why even judges have said it’s important to have a lawyer for these appeals!
Important: your appeal package should contain all the legal, procedural, and medical arguments that you want to make.
Here’s what you need to do to put together a complete appeal:
- Highlight the information the insurance company missed or failed to include in your claim review.
- Include a letter and records from your doctor or other medical experts with an accurate description of your diagnosis and condition, including restrictions and limitations, treatment plan and prognosis.
- Include an accurate job description provided by your employer, vocational expert, or yourself. Be precise and detailed when describing the “material duties” of your job.
- Research other long-term disability cases like yours where the claimant received benefits and include the opinions from those judges with your appeal.
- Ask your doctor(s) to respond directly to the insurance company medical “expert” who reviewed your claim and decided you were not disabled.
- If your condition is complicated, research and add articles from reputable medical journals that explain your disability and support your claim.
Bottom line: your appeal needs to show why you cannot work. You need to include evidence and support from your doctors and show where the insurance company failed to follow ERISA guidelines. You have two goals: first, win the appeal, but second, if the appeal is denied, make sure your claim is in the best possible position for a lawsuit.
Takeaway
Unfortunately, you cannot trust that the insurance company is acting in your best interests when reviewing your long-term disability claim. The appeal process protects you and gives you another shot to ensure that you get the fairest possible outcome. You often get just the one appeal, though, so make it count! Having an experienced disability attorney review your denial letter is a great place to start.
How BenGlassLaw Can Help
We have a free library of books, articles, and webinars that can help guide you through the appeals process.
If you have already had a claim denied or your benefits have been terminated and you would like to speak with an ERISA disability attorney, call our team at (703) 584-7277. We’ll review your denial letter and give you our thoughts on your case for free.
