POTS and Long-Term Disability Claims: How to Prove Disability

Postural Orthostatic Tachycardia Syndrome, commonly known as POTS, can make it difficult or impossible to sustain full-time employment.

People with POTS may experience a rapid heart rate, dizziness, severe fatigue, headaches, cognitive impairment, weakness, nausea, exercise intolerance, and fainting or near-fainting. Symptoms frequently become worse while sitting or standing upright and may improve when the person reclines.

Despite these limitations, long-term disability insurers often challenge POTS claims. The insurer may argue that the claimant’s examinations were normal, symptoms are subjective, treatment produced some improvement, or the claimant should be capable of performing sedentary work.

The critical issue is not simply whether the claimant has been diagnosed with Postural Orthostatic Tachycardia Syndrome. The issue is whether the condition prevents the claimant from performing the material duties of the occupation consistently and reliably.

Can POTS Qualify for Long-Term Disability Benefits?

POTS may support a long-term disability claim when the medical and occupational evidence establishes that the claimant satisfies the policy’s definition of disability.

Many policies initially require proof that the claimant cannot perform the material duties of his or her regular or own occupation. After a specified period, often 24 months, the definition may change and require proof that the claimant cannot perform another suitable occupation.

The exact policy language controls.

A diagnosis alone will rarely be enough. The claim must connect the claimant’s symptoms and limitations to the demands of the occupation.

Why POTS Can Prevent Sedentary Work

Disability insurers frequently assume that someone who can sit at a desk is capable of sedentary employment.

That assumption may be incorrect in a POTS claim.

Sitting upright for prolonged periods may cause tachycardia, dizziness, nausea, headaches, fatigue, and cognitive difficulties. Some individuals must recline, elevate their legs, or take unpredictable breaks to control their symptoms.

Sedentary work may also require the employee to:

• Remain upright throughout most of the workday
• Maintain concentration
• Attend meetings
• Work at a computer for extended periods
• Meet deadlines and productivity requirements
• Commute or travel
• Maintain regular attendance
• Make accurate and timely decisions

The ability to complete an activity briefly does not establish the ability to perform it throughout a full workday and workweek.

Evidence That Can Strengthen a POTS Disability Claim

A strong POTS LTD claim should document both the medical condition and its effect on occupational functioning.

Relevant evidence may include:

Diagnostic testing

Testing may include a tilt-table test, standing test, heart-rate and blood-pressure measurements, cardiac monitoring, autonomic testing, and blood work used to exclude other possible causes.

Not every claimant will undergo every test. The appropriate evaluation depends on the individual’s symptoms and medical history.

Detailed physician reports

Treating physicians should explain:

• The diagnosis and clinical basis for it
• The severity and frequency of symptoms
• Sitting, standing, and walking tolerance
• Whether the patient must recline
• The need for scheduled or unscheduled breaks
• Cognitive limitations
• Medication side effects
• Whether the patient can commute safely
• Whether the patient can maintain a predictable work schedule

A conclusory statement that the patient is “disabled” may not be enough. The physician should describe specific functional restrictions.

Evidence of the actual job duties

A job title may not accurately reflect the claimant’s occupation.

For example, an executive’s position may be classified as sedentary while requiring frequent travel, extended meetings, complex decisions, long hours, and continuous availability.

The claim should include the employer’s job description and a detailed explanation of the employee’s actual physical, cognitive, travel, scheduling, and productivity requirements.

Documentation of cognitive symptoms

Brain fog can be especially disabling for attorneys, executives, financial professionals, healthcare workers, educators, and others who perform complex work.

The medical record should document problems with concentration, memory, processing speed, multitasking, word retrieval, decision-making, and productivity.

A symptom and activity journal

A contemporaneous journal may document:

• Heart-rate changes
• Dizziness or fainting episodes
• Time spent upright
• The need to recline
• Cognitive symptoms
• Missed activities
• Medication side effects
• Recovery time after appointments or errands
• Better and worse days

The journal should be accurate and specific.

Why Insurance Companies Deny POTS Claims

POTS claims are frequently challenged because symptoms fluctuate and routine examinations may appear normal.

A claimant may demonstrate normal strength while sitting in an examination room but remain unable to sit upright, concentrate, commute, and work reliably throughout the day.

Insurers may also rely on limited daily activities or surveillance. Video showing a claimant driving, shopping, or attending an appointment does not necessarily prove an ability to work full time. It does not reveal the symptoms experienced afterward or the amount of recovery time required.

Partial improvement with medication, increased fluids, compression garments, or physical therapy also does not necessarily establish work capacity.

Improvement is not the same as recovery.

Common Mistakes in POTS LTD Claims

Common mistakes include:

• Relying only on the diagnosis
• Failing to document sitting tolerance
• Providing vague descriptions of fatigue or dizziness
• Using an incomplete job description
• Ignoring cognitive impairment
• Failing to document the need to recline
• Overstating or understating daily limitations
• Ignoring coexisting conditions
• Missing the administrative appeal deadline

POTS may occur alongside migraines, gastrointestinal disorders, joint hypermobility, autoimmune conditions, chronic fatigue, pain, anxiety, depression, and other impairments.

The insurer should consider the combined effect of all supported medical conditions.

What to Do If a POTS LTD Claim Is Denied

A denial should be analyzed carefully.

The claimant should determine:

1. What definition of disability the insurer applied
2. How the insurer classified the occupation
3. Which medical records and tests were reviewed
4. Whether the insurer considered the need to recline
5. Whether cognitive symptoms were addressed
6. Whether all medical conditions were considered
7. Whether the insurer relied on surveillance or social media
8. What additional medical, occupational, or vocational evidence is needed

A comprehensive appeal may include updated physician reports, responses to insurance-company medical reviews, diagnostic testing, occupational evidence, witness statements, a symptom journal, and vocational analysis.

In an ERISA-governed claim, the administrative appeal may be the primary opportunity to submit evidence. Important documentation should be provided before the appeal deadline.

The Bottom Line

POTS can prevent a person from maintaining the posture, stamina, concentration, attendance, and reliability necessary for full-time employment.

The strongest claims do more than establish the diagnosis. They explain how the claimant’s symptoms interfere with the actual duties of the occupation on a regular and sustained basis.

The Law Office of Justin C. Frankel, P.C. represents long-term disability claimants nationwide in claims involving POTS, dysautonomia, chronic fatigue, cognitive impairment, and other complex medical conditions.

Contact the Law Office of Justin C. Frankel, P.C. today for a free consultation and learn how an experienced ERISA disability attorney can help protect your rights and maximize your chances of success.

Justin C. Frankel is the founder of the Law Office of Justin C. Frankel, PC, a Long Island, New York headquartered law firm representing clients nationwide in disability insurance claims. For more information please go to our website www.jfrankellaw.com.

This article is provided for general informational purposes only and does not constitute legal or medical advice.