3 Common Missteps That Sway WC Disability Determinations

Determining disability involves a team of players whose roles aren’t always straightforward.
By: | May 21, 2019

Disability is a tricky area that has grown substantially in significance over the past few decades, with 1 in 20 working-age adults in the United States (5%) not working due to disability.

This number has risen from just 1% of working-age adults in 1965, now costing upwards of $200 billion annually.

In a paper written for Broadspire, Marco Iglesias, who boasts over 25 years of experience in workers’ compensation, disability evaluation/treatment and insurance leadership, outlines some of the most glaring obstacles that emerge during the evaluation process, when determining whether a worker should or should not receive disability benefits.

These common missteps are relevant to each player in the game, from doctors to injured workers to employers and benefits administrators.

1) Misuse of language

There are a number of terms that are often misused when determining whether a worker should receive disability, which can stall or unintentionally sway decision-making.  

  • Impairment vs. disability: An impairment, as described in the Broadspire paper, is “a significant deviation, loss, or loss of use of any body structure or body function in an individual with a health condition, disorder or disease.” A disability, on the other hand, is described by the American Medical Association as “activity limitations and/or participation restrictions in an individual with a health condition, disorder or disease.”

The distinction here is important, because an impairment that would prevent one person from doing their job — causing them to have, by definition, a disability — could have no impact on another person’s ability to do their job, depending on what the job duties are.

  • Limitations vs. restrictions: These two terms are often used interchangeably, but they are not the same. As Iglesias noted, “A limitation refers to what an individual is unable to do as a result of a medical condition. A restriction refers to what an individual should not do as a result of a medical condition.” For example, if an employee is prone to seizures, they are not unable to drive a forklift, but for the safety of themselves and others, they should not. This is a restriction rather than a limitation.

Why it matters: Confusing or conflating these terms can lead to inaccurate determinations of disability and can also cause confusion in communications between doctors, employees and claims professionals in the process of determining whether or not an employee should receive disability and to what extent. Using them correctly the first go-around can save everyone involved in the process an unnecessary headache.

2) Doctors using different processes to evaluate disability

Iglesias references a study performed in New Zealand, where researchers categorized how doctors determined disability in the case of lower back pain.

In the end, they found that there wasn’t one universal system, but rather four processes by which doctors came to their determinations.

Why it matters: While this study wasn’t performed in the United States, the takeaway — that doctors each have their own personal processes of evaluating disability — still applies.

As the paper noted, “It’s important to realize that there is very little in the way of scientific studies or evidence based guidance for most disability determinations.” So, essentially, doctors are left to their own devices.

Per the New Zealand study, depending on the doctor’s process, the patient could play a large role in the determination process — sometimes driving it completely — which isn’t how the system is designed to work.

3) Muddling of roles and responsibilities in the determination process

There are certain questions that doctors simply don’t have the experience to answer, like those in relation to an employee’s tolerance levels, which can only truly be determined by the employees themselves.

So, it’s important to be acutely aware of who is responsible for determining what throughout the process.

As noted by Broadspire, the employee is responsible for determining their tolerance; the employer is responsible for determining the employee’s employment, job and duty; doctors are responsible for determining the employee’s limitation, restriction, capacity and impairment and for providing accurate information surrounding these areas; and after taking all of this into account, the benefits administrator is responsible for determining the disability of the employee.

Why it matters: When these roles are unclear, determinations of disability can essentially be made by the wrong person, including the employee or the doctor, when really the burden of determination falls on the benefits administrator. &

Adjua Fisher is a freelance writer, editor and business owner living in Philadelphia. She is a former health and fitness editor at Philadelphia magazine. Adjua can be reached at [email protected]

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