In order to know whether you can do your job (or any other work in the economy), the Long Term Disability (LTD) insurance company needs to know what you are still able to do (your “functional capacity”), after considering the effects of your disability (“residual”). For example, if you can still sit and type for extended periods of time, but you cannot stand or walk more than two hours total in an eight hour day, your residual functional capacity is such that you may be able to perform sedentary work but not light, medium or heavy-duty work.
What Is Your Residual Functional Capacity (RFC)?
To learn what your residual capabilities are, the insurance company may ask for you to take an Attending Physician’s Statement (APS) form to your doctor (this form is also known as a Residual Functional Capacity form or a Medical Source Statement). If the insurance company claims handler does not believe the APS is sufficient (for example, if the doctor’s responses on the form are totally inconsistent with the medical records in the claim), the adjuster may schedule you an appointment to attend an “Independent Medical Examination” by a doctor hired by the insurance company. This doctor will then perform an RFC (residual functional capacity) assessment for your claim. The examiner will determine what level of exertion you are capable of performing, and what restrictions you have that may limit the jobs you can do. The medical examiner may also review your medical records and your doctor’s notes about your functional abilities and restrictions to come up with your RFC.
Custom Forms v. Generic Forms
What Level of Activity Are You Capable Of Performing?
Your physical RFC will determine whether you can perform sedentary, light, medium or heavy-duty work. For example, if your doctor has restricted you to walking and standing no more than two hours total in an eight hour day, your RFC will be for sedentary work. Here is a more detailed breakdown of the various exertional levels:
- Sedentary work. A sedentary job is one that is primarily sitting, with occasional walking and standing. To perform a sedentary occupation, you usually do not need to lift and carry more than ten pounds at a time, and you may be required to occasionally lift or carry things like files or small tools.
- Light work. Light work typically requires frequent walking and/or standing, as well as the ability to reach, push and pull with your arms or legs. Light duty jobs typically require the ability to lift and up to 20 pounds occasionally, and up to ten pounds frequently. If one can perform light work, one is generally considered capable of performing sedentary work.
- Medium work. A medium-duty job typically requires one to be able to lift and carry up to 50 pounds at a time, and the ability to frequently lift and/or carry up to 25 pounds. If one can perform medium work, one is generally considered capable of performing light and sedentary work.
- Heavy work. Heavy-duty work typically requires the ability to lift and carry up to 100 pounds at a time, and the ability to frequently lift and/or carry up to 50 pounds. If one can perform heavy work, one is generally considered capable of performing medium, light, or sedentary work.
- Very heavy work. Very heavy work typically requires the ability to lift and carry objects that weigh more than 100 pounds, and the ability to frequently lift and/or carry 50 pounds or more. If one can perform very heavy work, one is generally considered capable of performing all other levels as well.
Your RFC will also include any non-exertional restrictions, such as not being able to stoop, use your fingers, or remember instructions.
Your mental RFC will determine whether you can perform work-related mental activities. When evaluating the claimant’s mental residual functional capacity, the claims handler will look at four primary functional areas: (1) understanding and memory; (2) social interactions; (3) sustained concentration, persistence, and pace; and (4) adaptation to changes in the work environment.
Thus, a mental RFC form completed by a mental health professional (such as a psychologist or psychiatrist) should make reference to a claimant’s mental impairments due to the claimant’s mental conditions (for example, poor memory, decreased energy, illogical thinking, and so on). The mental RFC should also opine as to the claimant’s ability to persist in the areas of concentration and attention, as well as a claimant’s ability to interact socially in work settings, assimilate new information, and successfully engage in SRRTs (simple, routine, repetitive tasks).
How Your RFC Is Used
If your claim is still within the “own occupation” period, the LTD disability claims examiner will first use your RFC to determine if you can be expected to do your own job. For example, if your prior job was sedentary and your RFC is for sedentary work (or higher), the claims examiner will likely find you should be able to return to your job unless your RFC identifies further non-exertional restrictions (non-exertional impairments may include mental or emotional limitations, such as memory problems from a psychiatric or neurological disorder, or an inability to concentrate).
If your claim is within the “any occupation” period, then the claims examiner will review your RFC to determine whether you could return to any job in the economy.
Note: to be considered able to work, you should be able to work full time, attend work regularly, be productive at work, and not need to take frequent rest breaks.
Should You Obtain a Residual Functional Capacity Form from Your Physician for Your LTD Case?
A statement from a treating doctor can often make the difference between winning or losing a long term disability claim. But that does not mean any statement will do. The statement should not be too brief to be of any use or too conclusory. I cannot tell you how many times our office has received a call from an excited client and the client says the doctor wrote them a statement that will win the case. We tell the client to bring the statement into our office. It is an extremely note on a prescription pad that says little more than “My patient is completely disabled and unable to work”.
I’m afraid to say that this type of statement is extraordinarily useless to the insurance company disability claims examiner (who makes the decision on an application for disability or on the appeal).
There is no question that the LTD insurance company is very interested in receiving the opinion of a claimant’s treating physician. In fact, most insurance companies have an Attending Physician’s Statement to be filled out by a doctor as part of the disability claim application.
Who Signs the Residual Functional Capacity Form?
A doctor who submits a statement should be a treating physician. A treating physician is qualified to give a valid opinion as to the claimant’s medical condition and how the condition affects the claimant because the doctor has a history of treating the claimant.
What Should the Residual Functional Capacity Form Say?
Medical opinions only carry weight if they are specific enough to indicate the patient’s specific limitations and why the physician believes that his or her patient is disabled and unable to work.
For these reasons, a Residual Functional Capacity form should contain the following elements:
- It should identify the claimant’s diagnosed condition or conditions;
- It should indicate the date of the diagnosis;
- It should indicate the prognosis (or future outlook) for the condition(s); and
- Most importantly, it should identify all the various ways in which the claimant is functionally limited (which evidences how and why the claimant would be unable to sustain full-time work activities).
Regarding item number 4 above: it is usually most efficient and effective for a doctor to complete a check-off style form that allows the doctor to address the claimant’s level of impairment. For physical impairments, the doctor may opine as to the claimant’s physical strength level, their range of motion, their postural or ambulatory limitations (sitting, standing, walking, bending, crouching, reaching, balancing), their ability to lift and carry weight on an occasional or frequent basis, their deficits with regard to their senses (seeing, hearing, feeling, grasping, manipulating), and any other physical functional short-comings the claimant may have.
If the claimant’s disabling condition is mental, the treating psychiatrist or psychologist should indicate which cognitive deficits they have. For example, do they have trouble retaining information, learning information, concentrating, getting along with supervisors or co-workers, etc? Does the patent have a poor memory, decreased energy, illogical thinking, and so on? The mental RFC may also indicate the patient’s ability to persist in the areas of concentration and attention, as well as the patient’s ability to interact socially in work settings, assimilate new information, and successfully engage in SRRTs (simple, routine, repetitive tasks).
Why Doctors’ RFC Forms Are Better Than Medical Records
Many claimants think: “Well if my medical records are strong, why should I need an RFC filled out by my doctor (or psychologist or psychiatrist)?” There is a very good answer to this question. Medical records very rarely specify opinions or conclusions regarding the patient’s ability to work or not. A long term disability insurance claims handler is not a doctor who can easily translate medical findings into specific work-related impairments. This is why it is important for a doctor to “bridge the gap” between your medical diagnoses and your work-related impairments.
The Rationale for Doctors’ RFC Forms in LTD Claims
- A doctor’s RFC/APS form makes the LTD claims handler’s job easier;
- A doctor’s RFC/APS form allows a claimant to present a professional interpretation of the medical evidence, as opposed to simply presenting the medical evidence by itself;
- A doctor’s RFC/APS form is far superior to a short statement or letter written by a doctor on behalf of a claimant. (Such letters rarely, if ever, help to win a case.); and
- A doctor’s RFC/APS form can be instrumental in winning a disability case, mainly by allowing a doctor to specifically comment on a claimant’s limitations with respect to exertional ability, postural limitations, strength, range of motion, mobility, etc.
How An Attorney Can Assist You with Residual Functional Capacity Forms
A competent and experienced disability attorney will nearly always try to obtain a Residual Functional Capacity form from the claimant’s treating physician (physicians if more than one). This is because such statements can often “turn the tide” in a case and effectively win disability benefits.
You can use the Attending Physician Statement provided to you by the insurance company as your Residual Functional Capacity form. However, keep in mind that the same forms are used for every claimant, regardless of that individual’s specific impairments. In other words, the same APS is used whether the claimant has back pain, cancer, heart problems, or lung problems. Each medical condition results in specific impairments. That’s why my office has created specific Medical Source Statement forms for a multitude of medical impairments. We have specific forms for neck, back, heart, lung, shoulder, knee, hip, foot, fibromyalgia, and migraine headaches problems. This list is not complete. We literally have dozens of forms, including forms for less common medical conditions like dysautonomia and Lyme Disease.
Mr. Ortiz offers free consultations if your LTD claim has been denied or terminated. Call (888) 321-8131 today to discuss your legal rights.