Functional Capacity Evaluations in LTD Claims
Navigating long-term disability (LTD) claims can be distressing. Insurers can leave you with the impression they do not believe you. You may get a letter or an email from your insurer requesting that you attend a “Functional Capacity Evaluation” or FCE. Other times, your own lawyer may send you to an Occupational Therapist for an evaluation of your functional abilities.
We at Preszler Injury Lawyers know that attending to expert medical assessments can feel intimidating, especially when you are navigating insurance claims, litigation, and managing your own therapies. Our clients often ask:
- What is a Functional Capacity Evaluation?
- How will it affect my claim?
What Is a Functional Capacity Evaluation (FCE)?
A FCE is performed by an occupational therapist or other vocational expert, and is used to measure your ability to perform tasks. Tasks such as bending, lifting, carrying, pushing, pulling, balance, fine motor skills, and cardiovascular tolerance are tested through a battery of physical tests and questionnaires. The goal is to assess your functional limitations and determine if you are physically capable of performing your job. The FCE normally takes most of a day.
After the FCE, the evaluator will compare your test results to the job requirements of your profession. The report or expert will make their recommendations as to whether you are able to return to your work. If the expert concludes you can return to your work, they will often make recommendations for modifications or accommodations. The expert may determine that you are not able to perform your work, but you are able of doing other types of jobs. Finally, an FCE may determine that you are totally disabled.
Preparing for Your FCE: Tips to Accurately Demonstrate Limitations
We at Preszler Injury Lawyers understand that attending to these evaluations can be stressful and knowing what to expect, and how to act, can help you feel comfortable in the process.
On the day of your FCE, you will want to follow your normal daily habits. Always consult with your doctor first, but typically this means trying to get good sleep and following your normal morning routines, such as taking medications.
Ultimately, the objective of an FCE is to determine your limitations relating to your vocational abilities and capacity to perform them on a consistent, long-term basis. This means they are trying to measure your ability to work or do repetitive tasks 9-5 for 52 weeks a year, and not just a burst of your effort on any given day.
We have had clients who give 100% during an FCE and then can’t walk or move certain body parts the next day. If that happens, it is important to report your pain and limitations after the assessment. This will allow the expert to understand that you went beyond your ability to consistently do this work.
Part of the assessment is testing your effort through your heartbeat. It is important that you give it your all. If you do not try hard, it could negatively impact your claim.
How Insurance Companies Interpret FCE Results in Alberta LTD Claims
Every LTD policy will vary slightly based on the specific wording of the insurance contract. In LTD claims the first stage of disability is if you can do your own work. After 2 years (sometimes only 1 year) to qualify and be approved for LTD benefits, you have to be disabled not only from your own profession, but any occupation. It is important to understand that any occupation is not as broad as it sounds. Any occupation must pay close to your previous salary.
A long-term disability FCE will evaluate your ability to perform the job tasks related to your occupation, or any occupation. Usually, the insurers have worded their LTD policies so that you can only qualify for LTD benefits if you are determined to be fully disabled from work by a medical professional.
The problem arises if you feel you are unable to work in any capacity, but an FCE report, perhaps requested by the insurer, doesn’t support the result of full disability as needed for LTD benefits.
Challenging Unfavourable or Incomplete FCE Findings
Sometimes FCE reports or findings may not be favourable to your claim. While this report could negatively impact your claim, the FCE is just one piece of evidence regarding your claim. There are a few different ways to approach challenging a negative report.
Firstly, you or your lawyer can challenge the validity or reliability of FCE findings generally. Some current research suggests that FCEs are not always a reliable predictor of ability to return to work and that the validity and reliability of FCEs hasn’t been studied sufficiently in the past. In a scientific article for the British Journal of Occupational Therapy by Malcolm Joss, “The Role of Functional Capacity Evaluations in Occupational Therapy Vocational Evaluations,” the researcher explains that the research shows that FCEs “are not comprehensive enough to address all the dynamic and complex factors that can influence an individual’s work performance.”
Secondly, you can challenge the expertise of the evaluator themselves. The paper above also states that the “key component in any vocational evaluation is the clinical reasoning exercised by the occupational therapist, which is essential in producing credible conclusions and workplace recommendations from the information generated from an evaluation.” If the evaluator strays outside their expertise, that portion of the assessment would not be reliable.
Finally, you can arrange to attend another FCE to get a second opinion about your capacity and ability to work. Your lawyer will often send you to multiple medical experts to determine your injuries, and getting a positive second opinion can go a long way to strengthening your claim. This is especially important if the FCE you are unsatisfied with was requested by your LTD insurer, as the insurer’s interests are typically contrary to yours.
Working With Medical Professionals to Strengthen Your FCE Outcome
When attending an FCE, communicate with the evaluator. If you are lifting or doing other tasks without visible pain signs, that doesn’t mean that it doesn’t hurt! Ensure you communicate any issues or feelings of pain, instability, or discomfort during the evaluation as the evaluator does not know how you are feeling.
There are some things to avoid if you want to ensure you can get a report that provides clear reliable evidence for your claim.
Firstly, try not to see the evaluator as your enemy. You or they may be having a bad day, and the evaluator may not have the best bedside manner, but ultimately you want the evaluator’s report to be supportive of your LTD claim. If you act defensively or seem evasive, they may note this in their report, which could be interpreted as you being unreliable.
The second thing to remember is that almost everyone being evaluated in an FCE is in some level of pain and has some level of restrictions on their functioning as a result. It is important that you don’t overemphasize or exaggerate your pain responses, and that you try to keep a consistent level of effort during the evaluation process, as the evaluator will be using several different measures to gauge your effort and ensure you aren’t exaggerating your symptoms.
Remember that the evaluators are comparing the physical signs they see and can measure – such as heart rate and breathing, bulging muscles, altered body mechanics, involuntary movement of other accessory muscles, and cardiovascular signs, and comparing that to your outward signs of pain and effort – facial responses and other subjective measures of your pain responses. This just means that they are trained to look for signs of exaggeration, or atypical pain responses, and note those in their reporting to determine whether your reporting should be considered “reliable”.
If you Need Help with Your Alberta LTD claim or Responding to an FCE, Give Us a Call
Our Alberta long-term disability lawyers can help if you are responding to an FCE request or need to arrange your own. If you have been denied your LTD claim, or have questions about your claim, please give us a call, toll-free, at 1-888-494-7191. Our staff can take your call 24-7 and set up a free initial consultation with our lawyers about your claim.
