You should not assume that the insurance carrier will continue to pay benefits indefinitely once your long term disability claim is approved. Your disability insurance policy may state that benefits are payable until you reach retirement age. However, it does not guarantee that you will automatically continue to be eligible to receive benefits until then with no further review.
Disability claim examiners are required to review claims to make sure that you continue to meet the definition of disability. Some insurance companies review claims once a month. Others review claims every 3-6 months, or maybe even only once a year.
Regardless of how often your claim is reviewed, here are 10 tips to help you keep your long term disability claim approved.
Understand the Definition of “Disability” or “Disabled” Used to Evaluate Your Claim
The most important thing to know is how the policy defines the term “disability” or “disabled.” It is also important to note that the definition of “disability” varies from policy to policy. However, it is typically defined as “an injury or illness that prevents an individual from performing the duties of their ‘own occupation’, or perhaps ‘any occupation.'”
Many “own occupation” policies will switch to “any occupation” after a certain amount of time (usually after benefits have been payable for 2 years or 24 months). When a policy transitions from “own occupation” to “any occupation”, the insurer will typically conduct a review of the claim to determine if benefits are still payable.
For example, a grade schoolteacher must be on her feet, educating small children. She walks with them all day to the bathroom, recess, gym, lunchroom, etc.
Now let us say that our teacher has peripheral neuropathy. This requires the teacher to stay off her feet most of the day. In fact, the teacher must occasionally elevate her legs throughout the day. Under an “own occupation” definition of disability, she may qualify for disability.
Under an “any occupation” definition of “disability”, she may still be able to work as an administrator, like a vice principal. She can no longer manage the full responsibilities of a teacher, but still has the skills to work at a desk. Therefore, she would not meet an “any occupation” definition of disability.
Understand Time Limitations for Specific Conditions
Most group long-term disability policies have a 24-month limitation on claims arising from mental, nervous, and psychological impairments such as depression, anxiety, post-traumatic stress disorder. Most policies I have seen include some type of mental illness limitation, although the specific language varies from policy to policy.
Some policies also have a two-year limit on long-term disability benefits for chronic pain conditions such as arthritis and chronic back pain, and for medical conditions that are primarily diagnosed based on “subjective” complaints, including chronic fatigue syndrome, neuromusculoskeletal and soft tissue disorders, and fibromyalgia. I have seen a MetLife policy that has a 24-month limit on neuromusculoskeletal and soft tissue disorders, except where there is certain objective evidence.
You may be able to maintain approved status beyond the time limitation. To do so, you must prove that you suffer from another medical condition which prevents you from working.
Complete the Attending Physician Statement Correctly
The Attending Physician Statement (“APS”) is a disability claim form completed by your physician. The form asks about your diagnosis, prognosis, treatment plan, and any limitations or restrictions that may affect your ability to work.
Your physician may not know the answer to questions about your abilities such as how long you can stand or walk. The best way to make sure your APS is filled out correctly is to schedule an appointment with your doctor. This way, you can answer any questions your physician has while completing the form.
Treat Regularly with Doctors Who Regularly Treat Disabled Patients
Most disability insurance policies will only pay benefits if you are receiving appropriate care for your disabling condition. If you do not receive treatment for your condition, the insurance company will assume that you are not disabled. They will say that if you are still disabled, you would have continued to seek medical treatment.
It is also important that your doctor is supportive and willing to complete disability claim forms. Managing a disability claim is stressful, but it is even worse when your doctor refuses to fill out the necessary paperwork. You need a doctor who is willing to support your claim, even if that means extra paperwork.
Document All Limitations and Restrictions
How well your doctor documents your restrictions and limitations is critical to your disability claim. Your records should explain why you have certain limitations. For example, your records should state that you cannot stoop because of a herniated disc in the back.
Your limitations should also be supported by the medical evidence on record in your claim. For example, include an X-ray or MRI report indicating you have a herniated disc).
Seek Objective Testing If Possible
Objective testing techniques include chemical tests, electrophysiological studies (electrocardiogram, electroencephalogram, etc.), X-rays, MRIs, CT-Scans, blood tests, and psychological tests. A functional capacity evaluation may also provide objective clinical evidence to prove whether the claimant is physically capable of performing the usual and customary duties of a given occupation.
When objective testing is not available, a long term disability claim may still be validated with subjective evidence. Subjective evidence primarily includes the patient’s self-reports and the observations of friends and family. Psychological and neuropsychological testing are objective tools that may defeat the insurance company’s position that the claimant is malingering or over stating his or her disabling condition.
Document Activities of Daily Living and How Those Activities Have Changed
Document your daily activities and how they have changed in a statement to the insurance company. What activities are you no longer able to perform due to your medical conditions? How long do you need to rest after 30 minutes of activity? You need to tell your story in such a way that the insurance company is able to recognize why it is that you’re unable to work.
Do Not Believe That Once Approved, Always Approved
There is no such thing as “once approved, always approved” in a disability claim. Even if you have made it past the 24-month mark, your insurance carrier will continue to review your disability claim to decide if benefits are still payable. Insurance companies have the right to review a claim as often as reasonably necessary, even as often as every month.
Be Careful About Social Media Surveillance
Social media surveillance is increasingly being used by insurance companies to terminate long term disability claims. When your claim is under review, the claims adjuster will review your social media accounts. Use caution when selecting activities, and how you use social media to share this information.
For example: Margie has a spine disorder. She suffers from tremendous back pain, and days her symptoms prevent her from even leaving the house. One day, Margie is feeling good enough to attend a free concert in a park close to her home. She only attends for a brief time but shares a photo of her at the park with friends on social media.
The insurance company will claim that if Margie can go out with friends, she is well enough to work. Margie knows this is not true, and that her doctor has encouraged her to stay active. However, the insurance company will use this as an excuse to terminate her disability claim.
Watch Out for Video and Photo Surveillance
Claimants should also watch out for video and photo surveillance. An investigator will sit outside your house, usually for multiple days, and record your activities. They will document whether you drove anywhere, if you were using an assistive device, and if you had difficulty moving.
Video and photo surveillance is most common before an independent medical examination (IME). This is because the insurance carrier knows you will have to leave your home. Stay vigilant, make sure your activities align with your limitations, and use any assistive devices that have been prescribed to you.
Contact an Attorney for Help If Your Claim for Long Term Disability Insurance Benefits Is Terminated
We assist claimants with the long term disability appeal process. We also manage the handling of your long term disability claims after approval by your disability insurance company.
If your disability claim is cut off by your insurance carrier, we can help. Ortiz Law Firm is based in Florida, but represents claimants nationwide. Call us at (888) 321-8131 to see what we can do to help you maintain approval of your long term disability claim.