Why is my Adjuster Sending me to a Functional Capacity Evaluation (FCE)?

What you Should Know about Functional Capacity Evaluations

If your disability insurance adjuster has recently asked you to complete a Functional Capacity Evaluation (FCE), you’re probably wondering why — and whether you have to comply. This request often comes up when you’re already in the middle of a long, stressful claims process, and it can feel like just one more hurdle standing between you and the benefits you’re entitled to.

If this is where you’re at, take a breath — being asked to complete an FCE doesn’t mean your claim is being denied, and it’s actually one of the most common tactics insurers use, especially as your claim moves past certain milestones. Understanding why it’s happening now is the first step to protecting yourself.

The short answer is that your adjuster is using the FCE as evidence. If you’ve been severely injured or become permanently disabled and can no longer work as a result, your insurer will look for objective documentation of your physical limitations before approving or continuing long-term disability benefits. A functional capacity evaluation is one of the tools they lean on most heavily to make that determination. Very often, this request lines up with a specific point in your claim: the two-year mark, when the definition of disability in most policies shifts from “own occupation” to “any occupation.” We’ll explain exactly what that means and why it matters below.

An FCE is a comprehensive evaluation that assesses your ability to perform a range of physical tasks and activities, meant to produce an objective analysis of your ability to return to work. In other settings, an FCE can serve legitimate purposes like job matching and treatment planning. But when your adjuster orders one specifically to evaluate your disability claim, the results carry a lot of weight — which is exactly why it’s worth understanding what’s really going on before you attend.

When administered by a disability insurance carrier for this reason, the process is often biased and can yield questionable results, since the carrier’s goal may be to find a reason to deny or terminate your benefits rather than to fairly assess your condition. This can be difficult to navigate on your own, but an experienced long-term disability lawyer knows how to challenge unfair results and help ensure your benefits stay in place.

Hamilton Long-Term Disability Lawyer

Disability Benefits Denied?

Free Consultations. Always.

Why is my Disability Adjuster Sending me for a Functional Capacity Evaluation?

There are various scenarios in which you may be required to undergo an FCE, such as during your application process, even before you’re approved. A tremendously common time, however, is right around the two-year mark of receiving benefits. After two years, the definition of “total disability” in the context of disability benefits typically switches from “own occupation” to “any occupation.”

The “own occupation” definition applies to your first two years of benefits. This means you only have to prove that your injuries or disability prevent you from performing the core responsibilities of your current job, even with reasonable accommodations. This is done using evidence such as official diagnoses, medical tests, and accident reports.

After two years, most disability insurance policies switch to the “any occupation” definition. This means that to continue receiving benefits, you must now prove that you cannot perform the essential functions of any job for which you’re suited based on training, skills, and experience. This often comes with considerable pushback from your insurer, who will insist that you’re ready to go back to work. You’ll often need to provide additional documents and evidence to prove your case.

This is often when the functional capacity evaluation comes in. They will order that the examiner of their choosing perform this test. The report will provide other job options for which, based on this test, they believe you could be qualified. Since they now have “proof” you can work, they justify cutting off your benefits at this two-year mark.

However, especially when they get to choose the test provider, this leads to biased and incomplete results. Especially if the results are loaded into a computer system that automatically generates a list of possible jobs, the entirety of your symptoms and condition is not taken into account.

This is where the help of a long-term disability lawyer becomes invaluable. They know what to expect in these situations and can help you fight an unfair ruling made based on this test. They can help you gather medical evidence to counter these findings and build a strong case for keeping your benefits.

What is a Functional Capacity Evaluation?

In Ontario, a Functional Capacity Evaluation (FCE) is a comprehensive assessment that measures an individual’s physical abilities and limitations in relation to their capacity to perform work-related tasks. This evaluation is typically administered by a qualified healthcare professional, such as a physiotherapist or occupational therapist, who has specialized training in conducting FCEs.

An FCE is often requested by employers, insurance companies, or legal professionals when an individual has been absent from work due to an injury or illness and is seeking to return to their job. The primary purpose of the evaluation is to determine whether the person can safely and effectively perform the essential duties of their occupation or any other suitable work.

The evaluation process involves a series of standardized tests and simulated work activities that assess the individual’s strength, endurance, flexibility, and overall physical functioning. These tests may include lifting, carrying, pushing, pulling, and other job-specific tasks. The healthcare professional observes the individual’s performance, notes any limitations or difficulties, and may also monitor their heart rate, blood pressure, and other vital signs throughout the evaluation.

In addition to the physical assessment, the evaluator may consider the individual’s medical history, current treatment, and other disabling conditions that could affect their ability to return to work. They may also discuss the individual’s job duties and work environment to better understand the demands they will face upon returning to their occupation.

Once the FCE is completed, the healthcare professional prepares a detailed report outlining the individual’s physical capabilities and limitations, along with any recommendations for accommodations or modifications that may be necessary to facilitate a safe and successful return to work. This report is then shared with the relevant parties, such as the employer, insurance company, or legal representatives, to guide the decision-making process regarding the individual’s return to work.

It is important to note that an FCE is typically requested when an individual’s ability to perform their job duties is in question due to a medical condition or injury. The evaluation is not always necessary for every return-to-work situation. Still, it can be a valuable tool in assessing an individual’s readiness to resume their work responsibilities safely and effectively.

How Long Does a Functional Capacity Evaluation (FCE) Take?

The duration of a Functional Capacity Evaluation (FCE) varies depending on several factors, including the complexity of the individual’s medical condition, the nature of their job duties, and the specific tests and activities included in the evaluation. However, an FCE typically lasts between 4 and 6 hours and is usually completed in a single day.

The evaluation process is comprehensive and includes a variety of physical tests and simulated work activities, which can be time-consuming. The healthcare professional conducting the FCE needs to ensure that they have sufficient time to observe and assess the individual’s performance across a range of tasks and to gather all the necessary information to make an accurate assessment of their functional capacity.

In some cases, the FCE may be split into two shorter sessions on separate days, especially if the individual experiences significant fatigue or pain during the evaluation. This allows them to rest and recover between sessions and ensures that these factors do not compromise the results of the evaluation.

It’s important to note that the individual undergoing the FCE should be prepared to spend several hours at the evaluation center and should wear comfortable clothing and appropriate footwear to allow for a full range of movement during the physical tests and activities.

They should also bring any necessary medical documentation, such as recent medical reports or a list of current medications, to the evaluation to ensure that the healthcare professional has all the relevant information needed to conduct a thorough assessment.

What Does a Functional Capacity Evaluation (FCE) Test?

A Functional Capacity Evaluation (FCE) is a comprehensive assessment that tests an individual’s physical abilities and limitations in relation to their capacity to perform work-related tasks. The FCE will show both your capabilities and your impairments. Many tests are administered during an FCE; each test has a different purpose and measures your ability to perform certain activities, including material handling (lifting, pushing, pulling, and carrying).

The specific components of an FCE may vary depending on the individual’s medical condition, job requirements, and the protocols used by the healthcare professional conducting the evaluation. However, a typical FCE often includes the following tests and assessments:

• Musculoskeletal examination: This includes an assessment of the individual’s range of motion, strength, flexibility, and overall physical functioning of the affected body parts.
• Cardiovascular endurance: The evaluator may assess the individual’s ability to perform sustained physical activity by monitoring heart rate, blood pressure, and oxygen saturation during tasks such as treadmill walking or stationary bike riding.
• Material handling tasks: These tests assess the individual’s ability to lift, carry, push, and pull various loads, simulating common work-related activities. The evaluator may use standardized protocols, such as the National Institute for Occupational Safety and Health (NIOSH) lifting equation, to determine safe lifting limits.
• Postural tolerance: The FCE may include tests that evaluate the individual’s ability to maintain certain postures, such as sitting, standing, or crouching, for extended periods, as required by their job.
• Fine motor skills and dexterity: Depending on the individual’s occupation, the evaluator may assess their ability to perform tasks requiring fine motor skills, such as typing, writing, or manipulating small objects.
• Job-specific tasks: The FCE may include simulated work activities that closely resemble the individual’s job duties to assess their ability to perform them safely and effectively.
• Pain and effort assessment: Throughout the evaluation, the healthcare professional observes and records any signs of pain, discomfort, or excessive effort exhibited by the individual during the various tasks and activities.
• Cognitive and behavioural observations: While the primary focus of an FCE is physical functioning, the evaluator may also note relevant cognitive or behavioural factors that could affect the individual’s ability to perform job duties.

How to Prepare for a Functional Capacity Evaluation

You want to protect yourself going into an FCE and avoid pushing yourself past your physical limits or making your condition worse. To do this, it’s important to be honest and thorough and always stand up for yourself.

• In the days before your appointment, journal your symptoms, pain levels, and how your condition impacts basic daily activities. This will help you and the examiner approach the test with the right expectations.
• On the day of the assessment, be honest and upfront about your restrictions, and don’t hesitate to ask for appropriate accommodations if necessary.
• During the assessment, speak up immediately whenever something causes pain or discomfort. Do not push yourself beyond your limits or downplay any symptoms.

While these are good things to remember, your long-term disability lawyer will also prepare you for the assessment and let you know exactly what to expect. Our experienced long-term disability lawyers have seen many claimants go through these tests and subsequently deal with the fallout – be it faulty results, a biased interpretation, or an unfair decision by the insurance company.

What Happens If I Refuse to Attend My FCE?

It’s natural to want to refuse an evaluation that feels stacked against you, but doing so can carry real risk. Most disability policies require you to cooperate with reasonable requests for information, including medical examinations, as a condition of receiving benefits. If you refuse without a valid reason, your insurer may argue that you’ve breached your policy and use that as grounds to suspend or deny your claim, regardless of how strong your medical evidence otherwise is.

That said, “reasonable” is doing a lot of work in that sentence, and there are legitimate reasons an FCE request might be inappropriate or need to be challenged, such as being scheduled with an unqualified or clearly biased provider, or being asked to attend at a location or time that isn’t medically feasible for you. Before refusing or agreeing to anything, it’s worth speaking with a long-term disability lawyer, who can tell you whether your specific situation gives you grounds to push back, and can communicate with your insurer on your behalf so you’re not navigating that conversation alone.

Transferable Skills Analysis: An FCE Alternative

A transferable skills analysis is another test conducted by disability insurance companies, and it’s also common around the two-year mark.

This is a test that looks at an individual’s work history, skills, experience, etc., and provides a list of alternative jobs they’re supposedly suited for or could do with some training. The list is supposed to be of jobs that can be done with their current disability/physical limitations, but much like an FCE, the results can come back extremely biased or simply untrue.

Why is my Transferable Skills Analysis Suggesting Jobs I Can’t Do?

It certainly can be! When you undergo a Transferable Skills Analysis (TSA), ordered by your adjuster, as part of your disability claim, it’s important to understand that the process may be subject to bias, potentially leading to results that do not accurately reflect your full clinical picture or suggest unsuitable job options.

While a TSA aims to provide an objective assessment of your employability, there are several ways bias can be introduced into the process.

1. Limited input data: A TSA typically relies on information provided by the insurance company or the evaluator, which may not encompass the full range of your skills, limitations, and medical history. If the input data is incomplete or inaccurate, the results of the analysis may be skewed.
2. Subjectivity in data interpretation: Even when using a standardized system to input data, there is often room for subjectivity in interpreting and categorizing your skills and limitations. The evaluator’s biases, whether conscious or unconscious, can influence how your data is entered and analyzed.
3. Lack of consideration for your individual circumstances: A TSA may not adequately account for your specific medical conditions, treatment history, and unique challenges you face in returning to work. The analysis may suggest jobs that, while technically feasible based on the input data, are not realistic or sustainable given your full clinical picture.
4. Overreliance on automated systems: Many TSAs rely heavily on computerized databases and algorithms to generate job matches based on the input data. While these systems can process large amounts of information quickly, they may not capture the nuances and complexities of your situation, leading to irrelevant or unsuitable job suggestions.
5. Bias in the job market data: The databases used in TSAs often draw from historical job market data, which may contain biases related to factors such as gender, race, age, and disability status. This can result in the perpetuation of systemic biases in the job suggestions generated by the analysis.
6. Evaluator bias: The individual conducting your TSA, often a vocational expert or rehabilitation professional, may bring their own biases and assumptions to the process. Their personal beliefs, experiences, and understanding of your condition can influence the way they input and interpret your data, leading to biased results.

To mitigate these biases, your TSA must be conducted by a qualified, impartial professional with a thorough understanding of your medical condition and individual circumstances. The input data should be comprehensive and accurate, drawing from a variety of sources, including your medical records, functional capacity evaluations, and your direct input.

The results of your TSA should be interpreted in the context of your full clinical picture. They should be used as one piece of information in a broader vocational assessment rather than as a definitive determination of your employability.

Ultimately, while a TSA can be a useful tool in identifying potential alternative occupations, it is important to recognize its limitations and potential for bias. You should carefully scrutinize the results of your TSA and, when necessary, advocate for a more comprehensive and individualized assessment of your employability.

Contact Our Long-Term Disability Lawyers Today for a Free Consultation.

Unfortunately, it’s very common for insurance companies to terminate long-term disability benefits at the two-year mark, often using these tests to justify their decisions. For personal purposes, these tests can provide helpful and beneficial information to those trying to rebuild their lives and get back to normal. However, they become much more questionable when ordered and conducted by a “for-profit” disability insurance provider whose motive is to save money.

Our long-term disability lawyers have extensive experience navigating these situations and can help you at any point in the process. If you’ve recently been asked to undergo these tests, we can provide advice, guidance, and representation if the insurance company tries to use the results against you.

If you’ve already been denied or cut off due to a functional capacity evaluation, we can help you provide the necessary evidence to have your benefits reinstated. We’ll handle the complicated legal process and can negotiate with your insurer on your behalf – so all you have to do is focus on yourself and continue healing.

Our consultations are always free for Ontario residents and everyone else in Canada. Contact us at 905-333-8888 or confidentially via our website for no-cost advice about your rights and options.

Article FAQs