If your employer offers you long-term disability (LTD) coverage as part of a benefits package, or if you've purchased an individual policy on your own, you may be eligible to continue receiving most of your salary in the event you become unable to work. A person filing an LTD claim has a number of hurdles to clear, however, before benefits will be approved. The most important is to prove, with medical evidence, that you meet your insurance policy's definition of disability. But there are also requirements related to waiting periods, premiums, and minimum number of hours worked that you must keep in mind when applying for LTD benefits.
If you're thinking about filing an LTD claim, you should first consult the summary plan description in your long-term disability policy (or ask your employer's human resources department) for the policy's precise definition of "disability." Generally, you will be found "totally disabled" if you're unable, due to illness or injury, to substantially perform the duties of your occupation. If your LTD policy provides for "partial disability," you may qualify for benefits if you can no longer work full-time at your own occupation, even if you're capable of working full- or part-time at another job.
Many policies state that you cannot file an LTD claim if you are still on your employer's payroll.
As in Social Security disability cases, the most important factor in proving your disability in an LTD claim is the opinion of your treating doctor. As part of your application for LTD benefits, your doctor will be asked to complete a form or write a statement regarding his or her opinion on your condition. Your physician's opinion is critical, but the claims administrator will also want objective proof of your disability. Therefore, the administrator will also request all the medical records related to your disability, including relevant clinic notes, lab results, x-rays, MRIs, exam findings, and surgical reports.
To show that your disability is ongoing, you should continue to receive treatment from your doctor while your LTD claim is pending, and even after you are approved for benefits. Failure to continue treatment may be grounds for the insurance company to cut off your benefits.
It perhaps goes without saying that, if you're required to pay premiums for your LTD coverage, failure to make timely payments could cause your insurance to lapse. However, most people who are insured under LTD plans have free coverage through their employer.
Most employer-sponsored LTD plans require that you're a full-time employee at the time you become disabled. "Full-time" is usually defined as working at least 30 or 35 hours a week, but check your particular LTD policy to be sure.
Virtually all LTD policies have an "elimination period" between the time your disability occurs and when you can begin receiving benefits. This is essentially a waiting period during which you're not yet eligible for LTD benefits. Waiting periods are often three months or six months, but often last the same length as your short-term disability policy (most employees who have LTD insurance also have a short-term policy from the same company). Note that you'll likely be required to use up all sick leave before filing for short-term disability, and exhaust all short-term disability before filing for LTD.
There are exclusions for pre-existing conditions in many LTD policies. In general, a pre-existing condition is classified as an illness or injury that was diagnosed and/or treated within a certain period (often 90 or 180 days) before your LTD coverage began. If such a condition is present, you will not be paid benefits for any long-term disability that arises from that pre-existing condition for the first twelve months of your LTD coverage.
Before filing an LTD claim, make sure that your illness or injury is in fact covered by your LTD policy. Some policies have exclusions for particular diseases or workplace accidents. Also note that many LTD policies contain a 24-month limitation on disabilities caused in part by alcoholism, drug abuse, or mental or nervous conditions.
If you've been approved for LTD benefits, almost all policies require you to file for Social Security Disability benefits as well. That's because your insurance company can offset the amount you receive from Social Security against your monthly LTD payment. Because of this offset, your insurance company has a significant interest in seeing you approved for Social Security disability. It's not uncommon for an insurance company to hire a disability attorney to represent you in your Social Security case.
Similarly, if you're receiving LTD benefits based on an injury that occurred on the job, you may also be required to file for workers' compensation. Like Social Security, any Workers' Compensation payments you receive will offset your LTD benefits. It is important that you follow through on your Social Security and Workers' Compensation claims if you wish to continue receiving LTD benefits.