Filing a Long-Term Disability Claim: What to Know

Long-term disability (LTD) insurance pays monthly benefits to covered workers who become unable to perform the duties of their job for medical reasons. Unfortunately, the process of applying for disability benefits can be confusing, frustrating, and time-consuming, especially if you don't know what to expect. Here are several things to keep in mind if you're thinking about filing an LTD claim.

Examine and Understand Your LTD Policy

Whether you have group LTD coverage through your employer or an individual LTD policy, you should obtain the policy itself before even considering filing a claim. Your employer's human resources department can provide you with the plan and a copy of the summary plan description. For those with individual policies, contact your insurer. Request all LTD plan documents in writing and when you receive them, go over them carefully. Pay special attention to the following areas.

Time Limits

All disability policies contain strict time limits for when you must file your initial application and subsequent appeals. Missed deadlines present an easy excuse for insurers to deny your claim, so submit all paperwork within the time allotted.

The Definition of Disability

While there's no standard definition of disability, insurers often define it more or less as "an inability to perform, due to illness or injury, the material duties of your own occupation." Under this definition, you aren't required to prove that you're incapable of holding any job at all, only that you can't continue at your current position. But some LTD policies do define disability as an inability to perform any job. Others switch the standard from "own occupation" to "any occupation" after a certain amount of time, often 24 months.

Exclusions and Limitations

LTD policies generally don't cover disabilities caused by pre-existing conditions, commonly defined as conditions for which a person has received any sort of treatment in the 90 days (or some other period) before coverage becomes effective. Some policies hold that this exclusion applies only to the first year of coverage, but check your policy.

Certain medical conditions are not covered at all by LTD policies, even if they're not pre-existing conditions. Drug abuse, alcoholism, acts of war, attempted suicide, and disabilities arising from the commission of a crime are usually excluded from coverage. If your disability is based on a mental or nervous condition, like depression or anxiety, your benefits may sometimes be terminated after 24 months. (But there are often exceptions to this limitation for diseases like schizophrenia, dementia, and organic brain disease).

Waiting Periods

Your policy is likely to contain an "elimination period" of three or six months between the time you become disabled and when you can start receiving payments. Generally the elimination period coincides with your short-term disability policy, so there's no gap in coverage.

Filing for Social Security Disability

You'll almost certainly be required to file for Social Security disability benefits if you haven't already. That's because the LTD insurance company is allowed to offset your SSDI or SSI benefit against your LTD payment (subtract the amount of your Social Security check from your disabilityinsurance benefits). While your insurance company will sometimes try to arrange for a Social Security attorney to represent you, these attorneys often operate under a conflict of interest. You should consider obtaining your own attorney for your Social Security case.

Support Your Claim With Medical Evidence

Your medical records and the opinions of your doctor are two of the most important components of your LTD case. After you file a claim, your insurance company will obtain your recent medical records and ask your doctor to offer an opinion as to your limitations. Do not trust that the insurance company has all the necessary records, and do not assume that your records are entirely accurate. Ask to examine your claim file, and if medical records are missing, request them from the appropriate place and send them to your insurer. This includes all relevant hospital records, physicians' notes, MRIs, x-rays, and lab results. If there are inaccuracies in your file, ask your doctor to make any necessary corrections.

Finally, ask your doctor to write a detailed report regarding your medical history and your current limitations. Do not simply rely on the insurance company's forms. Be sure your doctor does not simply write that you're "disabled," as this is a legal term, not a medical one. Your doctor may charge you for writing a detailed report, but this is usually money well spent.

Exhaust All Your Appeals Before Going to Federal Court

If your LTD claim is denied at the initial level, you will have at least one and possibly two levels of administrative appeals. If you don't already have a disability attorney at this point, you should get one. Your attorney will work with you to supplement your file with as much favorable medical evidence as possible before your administrative appeals have ended. This is called "stacking the administrative record," and it's necessary because new evidence is almost impossible to submit once you get to federal court.

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