Topics in Disability Case Studies
Individual vs Group Disability Underwriting, group vs individual Definition of disability Duration of disability period Difference in contract language
Case #1 52 year old legal secretary, c/w on 4/2/13 with reported depression, job stress, and pain. Her claim was initially accepted for major depression based on mental health records. She now states that she is unable to work due to pain, fatigue, and fibro fog. She has been seen once by a rheumatologist who confirmed the diagnosis of fibromyalgia and advised regular exercise and a trial of gabapentin. She is taking hydrocodone 5mg 3-4 times a day from her family practitioner. An APS from the primary care doctor lists fibromyalgia as the primary diagnosis and depression as secondary. He says she is totally and permanently disabled. Issues: 1) How to assess impairment from pain and fatigue? 2) Potential medication side effects? 3) Cognitive complaints?
Case #2 42 year old school teacherwith long standing rheumatoid arthritis ceased work in mid 2012. Her current treatment includes: methotrexate 20mg weekly, adalimumab, and prednisone 5mg daily. The most current rheumatology chart notes say that she is generally doing well with mild swelling and tenderness in her wrists and second MCP joints. She has no deformity or limitation of joint motion. Recent laboratory studies include a sedimentation rate of 16, hemoglobin of 13 and a normal metabolic profile. Hand x-rays show no erosions or joint space narrowing. She has had one URI and one UTI in the past year. Issues: 1) Impairment related to arthritis? 2) Relationship of immunosuppression to risk of infections? 3) Ability to do light level activities?
Case #3 55 year old trial attorney with a history of a small inferior MI in December 2014. He was treated with a single vessel angioplasty and stent. His angiogram showed mild, multi-vessel disease. He was seen in follow up by his cardiologist on 3/1/2015. He denied any chest pain, shortness of breath, or leg swelling. His medications included aspirin, clopidogrel, metoprolol, and atorvastatin. A nuclear stress test showed a small inferior fixed defect but no evidence of reversible ischemia. His ejection fraction was estimated to be 55%. He was advised to exercise, minimize stress, and follow a low fat diet. He has resumed playing tennis and bicycling. On the APS form, coronary artery disease, s/p MI is listed as the primary diagnosis. No work impairment was mentioned. He says he cannot return to work due to stress and the risk of further heart damage. Issues: 1) Work capacity? 2) Risk of further heart damage? 3) Definition of stressful occupation?
Case #4 A 48 year old welder, ceased work on 4/1/14 due to advanced small cell lung carcinoma. He had significant weight loss as well as fatigue and weakness. His insurance became effective on 6/1/13. The pre existing period was 3/1/13-5/30/2013. During this time he was seen for a cough and some chest pain. A chest x ray showed a small nodule in the right upper lobe. He was treated with an antibiotic and improved. No follow up was scheduled. In early 2013 he presented with weight loss and a cough. A chest x-ray showed a right upper lung mass, which on biopsy was small cell cancer. Issues: 1) Work impairment? 2) Treatment during the preexisting period?
Case # 5 A 45 year male carpenter, a medium level occupation, developed a lower extremity DVT and pulmonary embolus after a long plane flight. He was treated with heparin followed by coumadin and support hose. Six weeks after the event, he is asymptomatic apart from some mild leg swelling. He will remain on anticoagulation for at least another four months. Issues: 1) What is his current functional capacity? 2) What are his work restrictions?
Case # 6 A 59 year old accountant was diagnosed with bilateral hip osteoarthritis, left greater than right, and had a left total hip replacement performed in March 2015. He had a satisfactory recovery but says that he cannot sit long due to hip pain. He has no other medical problems. Issues: 1) What is his functional capacity? 2) What are his limitations? 3) How do we evaluate his ability to sit?
Case #7 A 37 year old legal secretary has a long history of depression and fibromyalgia. She also has been diagnosed with migraine headaches. She takes amitriptyline regularly and uses sumatriptanand hydrocodone for acute headaches. She has been seen in an emergency room three times in the past six months for headaches. She says she has a headache at least once a week and misses three to four days of work per month due to headaches. She is treated primarily by her family practitioner. There are several references to work stress. Issues: 1) How do we verify the frequency and severity of her headaches? 2) How do we assess her degree of work impairment?
Case #8 A 49 year old construction worked has a long history of chronic low back and buttock pain. He has used hydrocodone for the past few years. In March 2015 he ceased work and underwent an L4-5 decompression and fusion. Notes from his spine surgeon in June 2015 say that he is still having some pain and stiffness, but generally is doing well and can advance activities as tolerated. No neurologic deficits were described. Notes from his internist comment on persistent back pain and need for hydrocodone. The claimant says that he cannot do any prolonged sitting, standing, or walking and is unable to return to work. Issues: 1) What is his period of total work impairment? 2) What is his current work capacity? 3) What is his prognosis for improvement?
Depression Underwriting Age & Gender Diagnosis Occupation Amount, BD, BP 38 male Depression VP of printing company for 11 years $4,000, 91 day, to age 65 Underwriting Information Counselor letter noting a 5-year history of weekly psychotherapy for a diagnosis of depression Questionnaire completed by applicant denies any current symptoms or job stress
Depression Underwriting (ctd) Limited data Value of a questionnaire Impact of obtaining additional medical records
Depression Underwriting (ctd) What are the favorable factors? What are the unfavorable factors? Can an offer be made? Rating? Rider? Benefit period?
Headache/Chronic Pain Underwriting Age & Gender Diagnosis Occupation Amount, BD, BP Underwriting Information Longstanding migraine history -under care of neurologist. Otherwise very healthy and active 6/02: HA s 1-2x/mo(4-5/10). Present since childhood but getting worse. Stress is a known trigger. Advised to use Excedrin for mild HA s and given Zomig& Vicodin for more severe HA s 6/03: Given Bextrato use prn 44 male Migraine Trial Attorney for 20 years $10,000/month, 91 day, age 65 2/04: HA s 1-2x/wk. Given Maxalt& Axertto try
Headache/Chronic Pain Underwriting (ctd) 9/04: HA s still 1-2x/wk. Axert & Maxalt ineffective 3/05: HA s now 2x/wk. Zomig & Vicodin provide some relief. Increasing stress and difficulty sleeping; given Imitrex & Zomig nasal spray
Headache/Chronic Pain Underwriting (ctd) What are the favorable factors? What are the concerning factors? Do you have enough information? If not, what else would you like? Can an offer be made? Rating? Rider? Benefit period?