Breathing is something most of us take for granted until a respiratory condition makes every breath a challenge. For people living with asthma, chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, or other serious lung disorders, even routine activities can become exhausting. Walking across a parking lot, climbing stairs, speaking for extended periods, or simply getting through a workday may require considerable effort.
When a pulmonary or respiratory condition prevents someone from performing the essential duties of their occupation, long term disability (LTD) insurance should provide financial protection. Unfortunately, obtaining benefits is not always straightforward. Insurance companies frequently challenge pulmonary disability claims, questioning the severity of symptoms, the medical evidence, and whether the claimant is truly unable to work.
At Newfield Law Group, we understand that respiratory disabilities present unique challenges in the LTD claims process. These conditions vary considerably in severity, may progress over time, and can affect people in ways that are not always apparent from a medical examination. Understanding why insurers deny these claims and how to respond can make an important difference in the success of your claim.
What Pulmonary and Respiratory Conditions Can Qualify for Long Term Disability?
A wide range of lung and respiratory disorders can interfere with someone’s ability to work. Some develop gradually, while others cause sudden and severe impairment. The diagnosis alone does not establish disability. The critical issue is how the condition affects the individual’s ability to perform the requirements of their occupation under the terms of their policy.
Common conditions involved in LTD claims include:
Chronic Obstructive Pulmonary Disease (COPD): A progressive lung disease that restricts airflow and makes breathing increasingly difficult. Although smoking is a leading cause, prolonged exposure to chemicals, industrial dust, diesel exhaust, and other occupational hazards can also contribute to COPD.
Asthma: A chronic condition involving inflammation and narrowing of the airways. Severe asthma attacks can cause significant breathing difficulties and may require emergency treatment.
Emphysema: A form of COPD involving damage to the air sacs in the lungs, reducing the ability to transfer oxygen effectively.
Pulmonary Fibrosis: Including idiopathic pulmonary fibrosis, this condition causes scarring and thickening of lung tissue, making it increasingly difficult to breathe.
Interstitial Lung Disease: A group of disorders that cause inflammation or scarring of lung tissue and can substantially reduce lung capacity.
Pneumoconiosis: Occupational lung diseases caused by inhaling certain types of dust, including silica, coal dust, and asbestos.
Occupational Asthma: Asthma triggered or aggravated by workplace exposures, including cleaning chemicals, paint, flour dust, animal allergens, and other airborne irritants.
Bronchiectasis: A chronic condition involving damaged and widened airways, often accompanied by persistent infections and breathing difficulties.
Pulmonary Hypertension: Elevated blood pressure in the arteries of the lungs, which can place significant strain on the heart and limit physical activity.
The difficulty for claimants is that two people with the same diagnosis may have very different functional abilities. Some individuals with COPD or asthma can continue working, while others cannot sustain even relatively modest physical activity. Insurers often use this variability to argue that a diagnosis does not establish an inability to work.
Why Do Insurance Companies Deny Pulmonary Disability Claims?
Respiratory disability claims can be particularly difficult because many symptoms are intermittent, fluctuate in severity, or become worse with exertion. A claimant may appear comfortable while sitting in a doctor’s office but experience significant shortness of breath after walking a short distance.
Insurance companies frequently rely on several arguments when challenging these claims.
Insufficient Objective Medical Evidence One of the most common reasons for denying a pulmonary LTD claim is the insurer’s position that the medical records do not adequately demonstrate functional impairment. A claimant may report persistent shortness of breath, fatigue, coughing, or difficulty walking. However, the insurance company may argue that these symptoms are subjective unless supported by appropriate medical testing.
Important diagnostic tests include:
- Spirometry: Measures how much air a person can exhale and how quickly. Measurements such as forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and the FEV1/FVC ratio help evaluate airflow obstruction.
- Body Plethysmography: Measures lung volumes and can help identify restrictive lung disease and air trapping.
- Diffusing Capacity (DLCO): Evaluates how effectively oxygen passes from the lungs into the bloodstream.
- Arterial Blood Gas (ABG) Testing: Measures oxygen and carbon dioxide levels in arterial blood.
- Pulse Oximetry: Estimates blood oxygen saturation.
- Imaging Studies: Chest X-rays and CT scans can identify emphysema, fibrosis, structural abnormalities, and other lung conditions.
These tests provide important evidence, but no single result necessarily establishes or disproves disability. Test results must be interpreted in the context of the claimant’s diagnosis, symptoms, treatment history, and functional limitations.
The Insurance Company Questions Self-Reported Symptoms
An insurer will not accept self-reported symptoms of shortness of breath, exercise intolerance, and fatigue. This does not mean the individual can work. It means the medical record must explain how exertion affects respiratory function and why those limitations prevent the claimant from performing occupational duties.
The Insurer Relies on an Outdated Occupational Assessment
Disability insurers frequently evaluate whether claimants can perform their previous occupations or alternative jobs. Unfortunately, these assessments may underestimate the actual demands of a profession. A report might conclude that someone can perform sedentary work because they can sit at a desk. But a job involving teaching, sales, real estate, financial trading, coaching, presentations, or business travel may require extensive walking, speaking, concentration, and sustained activity.
A person who needs frequent breaks to use an inhaler or nebulizer, cannot walk through an airport without stopping, or experiences breathlessness while speaking may be unable to meet those demands. An accurate occupational assessment must consider the full range of job responsibilities, not simply whether the claimant can sit in a chair.
The Change From Own-Occupation to Any-Occupation Coverage
Many LTD policies contain a particularly important provision: the definition of disability may change after an initial benefit period, often after 24 months. Initially, a policy may provide benefits if the claimant cannot perform the material duties of their own occupation. Later, the definition may change to require proof that the claimant cannot perform other occupations for which they are reasonably suited based on education, training, and experience.
This transition can create a significant obstacle for people with pulmonary disease.
An insurer may argue that someone who can no longer perform a physically demanding occupation can work in a sedentary position. However, even sedentary employment may be unrealistic for someone who experiences shortness of breath while speaking, requires frequent unscheduled breaks, or cannot maintain concentration because of respiratory distress.
How to Proceed with a Pulmonary or Breathing Disability Claim?
Claimants need to have more than symptoms. Robust medical support including appropriate quantifiable diagnostic tests must be prepared, along with the occupational information establishing how the disability impacts the person’s ability to perform the essential duties of their occupation. This is not an easy claim and will benefit from the representation of a skilled long term disability insurance attorney.
