When an individual experiences back pain so severe that he or she is unable to work, the process of qualifying for LTD with back pain may be challenging and overwhelming. LTD, or long-term disability insurance, may be offered through an employer or purchased independently on the private insurance marketplace. In either case, back pain long-term disability claims will need to be filed according to the protocols established by the insurance company and laid out in the documents describing your specific policy. LTD eligibility for chronic back problems can therefore be subject to different requirements than the coverage offered under other familiar types of disability insurance, such as workers’ compensation or other federal programs. Identifying the requirements mandated under your individual policy is an important first step toward qualifying for long-term disability with back pain issues. However, there are a few provisions that are common enough across the various types of disability insurance that they may be worth reviewing.
Back Pain Conditions That Qualify for Disability
While any list of conditions that qualify for LTD will necessarily depend on the terms of the specific policy, the stringent criteria set by the federal government for Social Security Disability Insurance (SSDI) applicants means that individuals who qualify for disability under SSDI guidelines will often also qualify for disability insurance through their private insurers. Additionally, it is very common for private LTD plans to require individuals seeking to claim their long-term disability benefits to file for SSDI first, or in tandem with their LTD claims process. As such, familiarizing yourself with the SSDI eligibility criteria may be a sound practical step if you are preparing to submit an LTD claim based on back pain.
As a general rule, under both SSDI guidelines and many private long-term disability insurance plans, the qualifying condition is likely to be the cause of the back pain, rather than the pain itself. In other words, it appears that a successful application may need to focus on demonstrating the nature and severity of the condition that causes your back pain, rather than focusing on the degree of pain you experience day to day.
Common Causes of Back Pain
The Mayo Clinic identifies the following conditions as common causes of back pain:
- Arthritis (with or without stenosis)
- Strains of muscles or ligaments
- Herniated discs (ruptured or bulging)
- Osteoporosis
- Ankylosing spondylitis or axial spondyloarthritis
Short term disability is not the right choice with respect to some of these injuries as some of the causes of back pain could be temporary. For example, strains of muscles or the ligaments that connect them (as well as inflammation of the tendons that connect muscle to bone) may heal with time and supportive treatment, which makes them likely causes of “sick days” and even in some instances short-term disability (STD).
It is important to understand that long-term disability is limited to conditions that are “chronic”, which means that they are either not expected to improve significantly over time, or whose improvement is expected to last beyond the period when STD would cover partial replacement of an individual’s income.
SSDI Back Pain: Skeletal Spine Conditions
The Social Security Administration (SSA) considers disorders of what the SSA calls the skeletal spine in the “musculoskeletal” category within the Blue Book’s Listing of Impairments. Problems of the skeletal spine include damage to, or dysfunction in, the bony vertebrae that run the length of an individual’s torso and serve to protect the spinal column. Also in the skeletal spine subcategory are disorders which affect the discs between vertebrae and those which involve damage or disease of the tissues connecting the bony structure of the spine to the muscles and other parts of the body around it.
Listing-level impairments (i.e., disorders that are common enough to appear before SSDI examiners regularly, and severe enough to often result in approved SSDI applications) that affect the back include:
- Skeletal spine disorders that compromise a nerve root (or nerve roots)
- Spinal stenosis in the lumbar region, if the cauda equina is compromised by the stenosis
- “Pathological fractures” in the skeletal spine, if they meet the criteria for severity established for this category of skeletal disorders overall
The SSA separates musculoskeletal disorders involving the spine from damage or disease impacting the “neurological spine” through the spinal cord to other parts of the body. Causes of back pain that are related to nerve function and are not primarily attributable to underlying problems of the bones, muscles, or connective tissues may be considered with the neurological spine.
Private LTD Back Pain
The assessment criteria used by a long-term disability insurance policy in determining whether a claim based on back pain is eligible can vary differently to those used by the SSA. Private LTD may or may not draw the same distinction as the SSA between skeletal vs. neurological spine issues. Sometimes, as well, LTD plans may call for evaluating back pain long-term disability claims according to a set of criteria the insurance company has established for handling cases involving disability for chronic pain.
Types of Evidence Used in Proving Back Pain Disability
The specific LTD eligibility for chronic back problems parameters, as well as how back pain long-term disability claims are categorized, will depend on the terms set out in your individual policy. However, qualifying for LTD with back pain will require the presentation of medical evidence in virtually all cases. The types of evidence used, and the procedures for filing a successful long-term disability claim, can vary from one policy to the next. Even so, there are a few types of medical evidence commonly used in proving disability due to back pain.
Results of Diagnostic Tests
The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) lists a number of imaging and other techniques that may be used in identifying the cause of back pain. Back pain long-term disability claims may call for records of some or all that have been used in diagnosing the patient filing a claim. Some examples include:
- Magnetic resonance imaging (MRI)
- Computerized axial tomography (CAT), often called a “CAT scan”
- X-rays
- Electromyography (EMG)
Blood tests are also sometimes used, typically if there are reasons to suspect an underlying inflammatory condition that might not show up on imaging tests like X-rays or MRIs. Whatever diagnostic tests are used in your particular case, it is likely that LTD eligibility for chronic back problems will require showing when each test was performed, as well documentation of the results you received.
Record of Treatment
One reason why identifying the dates of diagnostic exams may be important is that often doctors and other healthcare professionals will attempt several possible treatment protocols as they learn more about a patient’s condition. The two broad strategies for choosing treatment options are the principle of “conservative” treatment and the prevention principle.
The conservative treatment holds that in most cases it is preferable not to administer a greater degree of medical intervention than is necessary to achieve positive results. The prevention principle instead inclines toward applying treatment on a “just in case” basis.
While these two approaches may seem to be in tension, as a general rule medical professionals tend to use them in tandem to weigh the risks and benefits of any specific treatment in a particular case. The less likely the treatment itself is to cause harm, the more healthcare providers generally lean toward prescribing it even if they do not yet have a diagnosis showing positively that it is indicated. The more likely a specific treatment is to cause problems of its own, then the more conservative a medical professional is likely to be in prescribing that treatment.
One result of this balancing act that often takes place in the period between initial symptoms and positive diagnosis is that the reshuffling that tends to happen after each diagnostic test creates its own record of the patient’s case. Treatment history will always document what has been tried, but in many cases aligning the treatment history will also provide clues as to how severe the medical professionals understood a patient’s condition to be at each stage.
Attending Physician Statement
A very common requirement in qualifying for LTD with back pain is the “attending physician statement,” often referenced as “APS.” Although it is called a “statement,” in many cases the APS is more like a form that the physician who has been overseeing your healthcare is asked to complete and submit. Some sections that cover such items as descriptions of the patient’s condition or expected progress may be more open-ended than others.
If more than one healthcare provider has played a substantial role in managing the condition that has led you to establish LTD eligibility for chronic back problems, then the long-term disability insurance company may require you to submit an APS from each of these medical professionals.
Preparing for Back Pain Long-Term Disability Claims
Almost any LTD claim can be a frustrating process that takes longer than the individual filing the claim would like. Qualifying for LTD with back pain can be especially difficult because the pain itself is virtually impossible to document. Instead, LTD eligibility for chronic back problems will often depend on collecting medical evidence for the underlying condition that causes the pain. These records may include the results of diagnostic tests as well as statements from healthcare providers who have been involved in diagnosing and treating the patient. Generally speaking, the history of treatments that have been tried will be required as well. You can prepare yourself to apply for long-term disability by keeping your own log of symptoms and especially documenting your attempts to comply with any treatment regimen your medical team prescribes, and by familiarizing yourself with the specifics of your policy’s requirements for back pain long-term disability claims.
