How to File a Long-Term Disability Claim

Long-term disability (LTD) insurance pays monthly benefits to covered workers who can't do their jobs for medical reasons. Unfortunately, applying for LTD benefits can be a frustrating and time-consuming process—especially if you don't know what to expect.

Filing for long-term disability benefits can also be complicated. Here's what you need to know if you're thinking about filing an LTD claim.

Examine and Understand Your LTD Policy

Whether you have group LTD coverage through your employer (ERISA coverage) or an individual long-term disability insurance policy, you‘ll want a copy of the policy itself before you begin the process of filing a claim. You need to understand your LTD insurer's requirements before you file a claim.

If you have group LTD insurance through your work, your employer's human resources department can provide you with the plan and a copy of the summary plan description. If you have an individual policy, you'll need to contact your insurer directly. Request all LTD plan documents in writing.

When you receive your policy documents, go over them carefully. Pay special attention to the following areas.

Know Your LTD Application and Appeal Time Limits

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

How Does Your LTD Insurer Define 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 can't hold any job, only that you can't continue at your current position.

But some LTD policies define disability as an inability to perform any job (similar to Social Security's definition of disabled). Others switch the standard from "own occupation" to "any occupation" after a certain amount of time, often 24 months.

Understand Your LTD Policy's 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 medical treatment in the 90 days (or some other period) before coverage becomes effective. With some policies, this exclusion applies only to the first year you're covered by an LTD plan. But check your policy, because it could be different.

Certain medical conditions aren't covered at all by LTD policies—even if they're not pre-existing conditions. Mose LTD insurance policies won't cover injuries or illnesses caused by any of the following:

• drug abuse or alcoholism
• acts of war
• attempted suicide, and
• those arising from the commission of a crime.

If your disability is based on a mental or nervous condition, like depression or anxiety, some policies will terminate your LTD benefits after 24 months. But many policies make exceptions to this limitation for conditions like:

• schizophrenia
• dementia, and
• organic brain disease.

(Learn more about when an LTD insurer can terminate your coverage.)

The Long-Term Disability Waiting Period

Your policy will likely contain an "elimination period" of three or six months between when you become disabled and when you can start receiving payments. Generally, this waiting period lasts as long as your short-term disability insurance, so there's no gap in coverage.

How to Apply for Long-Term Disability

The process of applying for long-term disability benefits differs a good deal from the Social Security disability application process. And there are a few differences in procedure depending on whether you get your LTD insurance through your employer or you have a private policy. But all disability claims start with an application.

If your employer provides your long-term disability coverage, request an application (and instructions) from your company's HR department or your manager. If you have a private policy, contact your insurance company to request an LTD application. Some insurers allow you to apply online.

Most LTD applications are split into three parts:

• you complete the first section
• your employer completes a part, and
• your doctor completes another part.

Your part of the LTD application: You'll provide the insurer with all your identifying information (name, Social Security number, and so on). You'll also explain why you're disabled and when your injury or illness began. And you'll need to provide names and contact information for all your medical providers.

Your employer's section: This part will ask about your work history with the company, including when you first became eligible for LTD coverage. The employer will also explain details about your job, such as:

• your job title
• your job duties
• the physical and mental skills needed to do your job, and
• when you stopped working.

Your employer will also be asked about any other income or benefits you're entitled to (like short-term disability benefits or workers' compensation).

Your doctor's statement for the LTD application: Your doctor will need to supply information for your LTD application. You'll need your doctor to provide detailed statements about your condition, including the following:

• your diagnosis
• your symptoms
• the treatments you've had (like surgeries and physical therapy), and
• your prescribed medication(s).

Your doctor will also need to provide details about your physical and/or mental limitations and how long before you'll be able to return to work (if ever). Don't rely solely on the insurance company's forms. Ask your doctor to write a detailed report on your medical history and your current limitations.

And be sure your doctor doesn't simply write that you're "disabled," as this is a legal term, not a medical one. Your doctor should describe the work activities that your condition prevents you from doing, and why. Your doctor might charge you for writing a detailed report, but this is usually money well spent. (Learn more about getting your doctor's support for your disability claim.)

Make a copy of your application: Make a copy of your completed long-term disability application, including your doctor's statement and any medical records you submit to the insurance company. Keep the copies for your records.

Medical Evidence Needed to Support Your LTD Claim

Your medical records and your doctor's opinion 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 about your limitations.

Don't trust that the insurance company has all the necessary records, and don't assume that your medical records are entirely accurate. Ask to examine your claim file and check that all relevant medical information there, including the following:

• hospital records
• doctors' notes
• imaging test results (like MRIs and X-rays), and
• lab results.

If any medical records are missing, request them from the appropriate place and send them to your insurer. If you find something inaccurate in your file, ask your doctor to make any necessary corrections.

LTD Policies Usually Require You to File for Social Security Disability

Most long-term disability policies will require you to file for Social Security disability benefits if you haven't already. The LTD insurance company is allowed to "offset" your SSDI or SSI benefit against your LTD payment—that is, the insurance company will subtract the amount of your Social Security benefits from your LTD benefits.

While your insurance company might try to arrange for a Social Security attorney to represent you, these attorneys might operate under a conflict of interest. You should consider hiring your own disability attorney for your Social Security case.

What If Your LTD Claim Is Denied?

If your LTD claim is initially denied, you'll have at least one or two administrative appeals available to you. As with filing your claim, you'll have a limited amount of time to file an appeal. Check your policy for the deadlines.

If you don't have a disability attorney before you appeal a denial, 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.

Adding evidence this way is called "stacking the administrative record." It can be extremely helpful to your claim if you have to sue the LTD insurance company, as new evidence is almost impossible to submit once you get to federal court.

Learn more about hiring an attorney to help with your LTD claim.