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by ArthritisSupport staff
July 26, 2000
(Editor’s Note: On Friday, July 21, 2000, ArthritisSupport.com had an exclusive interview with disability expert Scott E. Davis, Esq., in which we discussed meeting the criteria to qualify for disability insurance when suffering from rheumatoid arthritis. Here’s what he had to say.)
ArthritisSupport: Mr. Davis, how does someone with rheumatoid arthritis qualify for disability insurance?
Davis: First of all, let’s make sure we’re talking about rheumatoid or inflammatory arthritis. This category of impairment under the law requires a great deal of documentation, and it’s somewhat different from qualifying for disability with osteoarthritis. For RA, they want to see even more documentation and more lab tests proving inflammation and swelling.
But if you have been told you do have RA, the first thing you must do is to make sure you are treated by a board certified rheumatologist. This is a medical doctor who specializes in chronic conditions characterized by inflammation, muscle soreness and stiffness, and pain in joints and associated structures.
Rheumatologists will know about the proper tests needed to help you qualify for disability. And federal law mandates that a medical specialist’s opinion is entitled to more weight than a non-specialist’s. So even if your GP or internist may make the initial diagnosis, make sure you see a specialist.
ArthritisSupport: What kinds of tests are required for documenting the case?
Davis: Before any tests are administered, the doctor must first give proof that there is a history of persistent joint pain, swelling and tenderness involving multiple major joints. These are the hip, knee, ankle, shoulder, elbow or a combination of the wrist and hand.
The doctor must also note signs of joint inflammation (swelling and tenderness) on the current physical examination despite prescribed therapy for at least three months.
ArthritisSupport: You mean you have to still have symptoms after treatment to qualify?
Davis: Right. That’s what makes qualifying particularly difficult. However, you should be aware that even if you don’t meet the official criteria under the law, you may still be eligible for disability. That doesn’t mean you shouldn’t get the proper documentation, though, which includes the tests I mentioned before.
ArthritisSupport: So first you need to have the symptoms for at least three months after being treated. Then you need tests to prove you have RA?
Davis: Yes, but any rheumatologist will get these tests, most likely. At least one of these tests must corroborate that there is actually an immune disorder. These are: a positive serologic test for rheumatoid factor ; or an antinuclear antibodies test (an ANA test); or an elevated sedimentation rate (called a SED rate); or a biopsy of synovial membranes, which most people never get.
ArthritisSupport: So let’s say the rheumatologist tells me I need to take a major drug like the steroid Prednisone to treat my RA. Do I have to take it?
Davis: If you decline treatment, you need to have a justifiable excuse, which is the exact phrasing used under the law. How this is interpreted, however, will vary from judge to judge. My advice is that you exhaust every medical option before you refuse treatment.
ArthritisSupport: But what if I’ve taken Prednisone before and I know it makes me sick?
Davis: If you have that documented in your medical records, the judge may very well accept that reasoning. But I’d advise at least trying the treatment your doctor recommends for several reasons. One, your doctor isn’t going to be thrilled if he or she tells you to do something and you don’t follow through. You don’t want to lose your doctor’s support. And two, I think it’s important to at least try everything that mainstream medicine can offer. Then you’re in the position for having a justifiable excuse to decline treatment. If the side effects are harmful and the doctor can document that, you have a story to tell as to why you’re not taking the medication that can minimize your symptoms.
ArthritisSupport: You mentioned that you can still get disability even if you don’t qualify by the code’s strict language
Davis: Most people don’t qualify under the code. If your condition is equal in severity to the criteria you can qualify. For example, let’s say you don’t have persistent inflammation after three months of therapy, but you have a sky-high rheumatological factor. That would effect the outcome.
Another way to qualify is to combine other disorders. If you happen to be depressed in addition to having RA or you have carpal-tunnel syndrome that causes other limitations you can combine those conditions and have enough severity to qualify for disability.
If your limitations are severe as a result of the condition, you can still be declared disabled. The easiest definition of disability is that the person is unable to sustain an unskilled sedentary occupation full time week in and week out.
It is on the basis of this that people generally win their cases.
ArthritisSupport: One more question. Do you need an attorney to win a disability case?
Davis: It’s conceivable to win without one, but you should have an attorney. Most disability attorneys work as I do, without being paid unless you win your case, so you really have nothing to lose. And most attorneys will be able to talk to the doctor and help get the documentation you need to win your case.
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