Physicians are being asked to fill out disability forms by patients for two COVID indications: (1) patients who have sustained permanent injury from a COVID-19 infection and (2) patients with risk factors who are fearful that they could have severe infection or death if they acquire COVID-19 in their workplace. So what should you do when presented with one of these forms?
Understanding the disability process
The definition of disability and the requirements to get disability vary depending on whether the disability benefits are coming from Social Security, Worker’s Compensation, or a disability policy from a commercial insurance company. In general, permanent disability is when there is a medical condition that prevents a person from performing their job and is expected to be present for > 12 months. In some cases, a nurse practitioner or physician assistant can fill out disability application forms for a patient but most of the time, the disability-granting organization will require the forms to be filled out by a physician.
Disability-granting organizations recognize that there is often an inherent conflict of interest when a patient’s personal physician fills out a disability application. First, that physician generally feels a responsibility to be the patient’s advocate and usually wants to be nice to their patient. Second, the patient is paying their physician for their office visits and their time to fill out the forms. And third, the physician often does not want to risk losing a patient by refusing to fill out the disability application. For these reasons, the disability insurance company will usually require an “independent medical examination” by a physician experienced with the patient’s particular medical condition. The physician is one that does not have an existing doctor-patient relationship with the disability applicant and is paid by the insurance company for their unbiased opinion in order to eliminate financial conflict of interest. The insurance company or other disability-granting organization will then have a staff member or committee knowledgeable in disability determine whether the applicant warrants disability benefits based on the independent medical examiner’s findings. In some situations, the disability process may involve a hearing with a judge or magistrate. The goal of this process is to get disability benefits to those persons who are truly disabled and avoid paying benefits to those persons who are not truly impaired.
Although there is a lot of variation between different disability-granting organizations, the common requirements to be granted disability include:
- The medical condition must either be new since the applicant began employment or if it is a pre-existing condition, it must have worsened since the date of initial employment.
- The medical condition must have a diagnosis (or tentative diagnosis). A symptom alone, such as shortness of breath, is generally not grounds for disability unless there is a diagnosis to go along with it (such as COPD).
- The medical condition must be of sufficient severity to prevent the applicant from doing their regular employment duties. Here, the applicant’s specific job requirements have to be taken into consideration – for example, knee arthritis that impairs walking has a different disability implication for someone who hangs drywall for a living than it does for a medical transcriptionist.
- The medical condition is expected to be “permanent” which generally means lasting at least 12 months.
- There must be objective evidence that the condition causes impairment. For this reason, it is very difficult for patients with chronic pain syndromes (migraine headache, fibromyalgia, etc.) to get disability without collaborating x-ray, EMG, or physical examination abnormalities. Similarly, applicants with conditions such as chronic fatigue syndrome that lack abnormalities on diagnostic tests are often denied disability.
Patients seeking disability after COVID infection
Shortness of breath and fatigue attendant to COVID-19 infection can last for weeks or even months. However, these symptoms will ultimately improve in most patients with mild to moderate COVID-induced heart or lung disease. For this reason, it is prudent to initially recommend temporary disability, rather than permanent disability. Even the sommelier who loses his/her sense of taste and smell due to COVID will usually have those senses return within a year.
Post-COVD lung disease
Patients seeking disability for post-COVID dyspnea need to have objective testing showing impairment. Although x-rays can be supportive, testing usually requires pulmonary function tests. Many disability-granting organizations will use the American Medical Association’s Guides to Permanent Impairment as a resource. This guide divides pulmonary impairment into five categories from 0 (no impairment) to 4 (45-65% impairment of the whole person).
COVID-19 usually causes pulmonary impairment by post-inflammatory pulmonary fibrosis which can be identified on a high resolution chest CT scan and often on simply a plain chest x-ray. Post-inflammatory pulmonary fibrosis will cause a reduction in the FVC and DLCO. Patients with obstructive lung disease (COPD or asthma) will have a reduction in the FEV1 with a normal (or slightly reduced) FVC – obstructive lung disease is considerably less common following COVID-19 but can occur occasionally. The table above should be used as a guide but must be interpreted in the context of the patient’s job requirements. For example, a laborer might be unable to perform regular job duties with PFTs in the class 2 range whereas someone with a desk job might not be impaired until they reach class 4. Also, a furnace repairman with class 1 PFTs who requires home oxygen might be unable to work if he/she cannot wear oxygen around open flames of a gas furnace. Patients with the worst post-inflammatory pulmonary fibrosis will be on chronic home ventilators – these patients cannot do pulmonary function tests and anyone with fibrosis that bad does not need additional testing to warrant permanent disability.
The cardiopulmonary exercise test is one of the most under-used tests when it comes to disability. For a guide to interpreting this test, see my previous blog post. This test allows the physician to determine if a patient’s shortness of breath is due to lung disease, heart disease, or deconditioning. To determine if a patient is objectively impaired, the key value is the maximum oxygen uptake, or mVO2. This test can be particularly helpful if the patient has shortness of breath out of proportion to the findings on the regular pulmonary function tests.
Post-COVD heart disease
COVID-19 can also cause myocarditis and can lead to impairment from heart failure. Myocarditis will often show up best with a cardiac MRI but just having radiographic evidence of myocarditis does not necessarily mean that the patient is impaired from myocarditis. For this, you need some evidence that the function of the heart has been affected. Most commonly, this will be a measurement of the ejection fraction. Although the ejection fraction can be measured by cardiac MRI, it is cheaper and easier to obtain by a cardiac echo. If the patient’s symptoms are out of proportion to the abnormalities on the cardiac echo, then once again, the cardiopulmonary exercise test can be valuable to determine impairment.
Post-COVD chronic fatigue
The generalized fatigue after a COVID-19 infection can last for a long time. In many ways, these patients resemble those with chronic fatigue syndrome. In addition to excluding heart disease or lung disease as a cause of the fatigue, these patients generally need a fairly extensive metabolic work up to exclude anemia, thyroid disease, kidney disease, liver disease, or electrolyte imbalance. In addition, sleep apnea is often a consideration. Most of the patients with severe COVID-19 infection had some co-morbid disease to begin with, such as diabetes, heart failure, or obesity which can also contribute to fatigue. Although post-COVID fatigue may warrant temporary disability while the patient recovers from the COVID infection, patients will find it very difficult to get permanent disability unless there is some objective test abnormality to attribute the fatigue to. Patients with fatigue will often benefit by physical therapy initially and then an exercise program later.
Patients seeking disability to avoid COVID infection
In the summer and fall of 2020, I had a number of patients who went on temporary disability because they had workplace exposure to COVID-19 and had underlying conditions that put them at risk of severe infection or death. These were often elderly or immunocompromised persons who worked in places like hospitals, schools, or restaurants. However, since the availability of COVID vaccines, the risk of severe COVID infection has markedly lessened. Furthermore, from a pragmatic standpoint, there is simply not enough money to put everyone with a COVID-19 risk factor on disability simply because they might get infected in the workplace. The three main risk factors are obesity, diabetes, and age – 42% of Americans are obese, 10.5% of Americans have diabetes, and 22% of Americans are over age 60. Some of these people have argued that they do not want to get a COVID vaccine and therefore they are still at risk in the workplace – my opinion is that they may have the right to decline a vaccine but that does not give them the right to then claim disability to avoid a vaccine-preventable condition. The one possible exception to this is patients with common variable immune deficiency. These are people who cannot make antibodies on their own and consequently, vaccines just do not work. Many of them take IgG replacement therapy and some IgG replacement products have been shown to contain anti-COVID antibodies but it is prudent to check with the manufacturer to confirm that the patient is getting a product containing anti-COVID antibodies.
Some patients seek disability because they have a condition that prevents them from wearing a mask. There are now enough other options, such as plastic face shields or PAPRs, that inability to wear a face mask is no longer grounds for disability in the vast majority of work environments.
The bottom line is that the desire to avoid workplace exposure to COVID-19 is no longer grounds for disability except in exceedingly rare situations
Disability is mostly avoidable
If a person is fully vaccinated, then the chance of that person getting a severe enough COVID-19 infection to result in permanent disability is very, very low. The risk will be even lower for those persons who have received a booster vaccine. Most Americans who are hospitalized with severe COVID infection and who get post-inflammatory pulmonary fibrosis or myocarditis are unvaccinated.
The best way to prevent disability from COVID-19 is to get vaccinated. We don’t need more tombstone epithets reading “I should have gotten a vaccine”
November 16, 2021
