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Do you need a definite diagnosis to claim disability?With some chronic debilitating conditions, a firm diagnosis may be impossible to achieve, particularly if you are seeing more than one health care provider for care. This should not prevent you from obtaining long-term disability benefits if you cannot work. Now, the truth is that if you don't have a firm diagnosis, you will likely need the services of an experienced long-term disability attorney to help you put together your appeal. These claims can often be tough to prove, but our firm has extensive experience handling these kinds of claims and has helped countless Virginia residents regain their benefits after a denial.

Example of Claim Being Denied Due to Lack of Definitive Diagnosis

In a recent case, Metropolitan Life Insurance company was presented with a claimant who's doctor said he suffered from an "undiagnosed neurological condition," with secondary diagnoses of optic neuritis and fibromyalgia.

A functional capacity test showed that the claimant had reduced endurance for work and a vocational expert reported that the claimant would not sustain work on a regular basis.

MetLife denied the claim.

The court found that MetLife abused its discretion in denying the claim because:

  1. MetLife placed too much emphasis on the absence of a unifying diagnosis
  2. MetLife ignored the results of the functional capacity exam
  3. MetLife did not seriously consider the vocational expert report
  4. MetLife failed to have a valid conversation with the treating doctors.

Consumer Tip: documenting your functional impairment may be more important than arriving at a firm, agreed upon, diagnosis.

Ben Glass
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Ben Glass is a nationally recognized ERISA disability & life insurance attorney in Fairfax, VA.