When an insurance company approves a long-term disability (LTD) claim, many claimants assume that their benefits will continue indefinitely into the future. However, insurers are not required to approve benefits forever. Instead, they conduct periodic reviews to determine whether a claimant still meets the policy’s definition of disability.
Understanding how and why these reviews occur can help you prepare for and reduce the risk of benefit termination.
Why Insurance Companies Conduct Periodic Reviews
Disability insurers conduct periodic claim reviews to verify that a claimant remains eligible for benefits. These reviews help insurance companies confirm that claimants are still unable to work due to their medical conditions and that they are actively receiving appropriate treatment.
Another reason for periodic reviews is that most LTD policies have time-based limitations or changing definitions of disability. For example, many policies define disability based on the claimant’s “own occupation” for the first 24 months, but after that, the definition changes to an “any occupation” standard. At that point, the insurer reevaluates whether the claimant qualifies under the new, more restrictive terms.
In some cases, insurers also conduct reviews to detect potential fraud, ensure that claimants are complying with treatment, and look for any vocational changes that may affect eligibility.
How Often Are Disability Reviews Conducted?
The frequency of long-term disability reviews varies depending on the insurer, the terms of the policy, and the nature of the disability. Some claimants may experience frequent reviews, while others may go years between major reviews.
- Monthly or Quarterly Reviews: Some insurers require ongoing updates through claimant forms or physician statements every few months.
- Annual Reviews: Many insurance companies conduct a comprehensive review at least once a year, requesting updated medical records and sometimes requiring additional evaluations.
- Major Definition Changes: A more detailed review often occurs when the policy shifts from an “own occupation” to an “any occupation” standard, often at the two-year mark.
Reviews may also be triggered by red flags, such as a physician noting improvements in medical records, gaps in treatment, or inconsistencies in a claimant’s reported symptoms.
What Happens During a Review?
A standard LTD review may include a request for updated medical records and forms that require you to describe your current symptoms, daily activities, and treatment compliance. The insurer may also require an independent medical examination (IME) or a functional capacity evaluation (FCE) to assess physical limitations.
Some insurers go a step further and conduct surveillance or review social media activity to look for evidence that contradicts a claimant’s reported limitations. For example, a claimant with severe back pain who posts photos of themselves hiking might be subject to scrutiny.
If the insurer determines that a claimant no longer meets the policy’s definition of disability, it can terminate benefits. This can be appealed, but the process requires strong medical evidence and a well-documented case.
How to Protect Your Benefits During a Review
Because long-term disability insurers look for reasons to deny claims, claimants should take proactive steps to protect their benefits:
- Maintain Regular Medical Treatment: Consistently seeing your doctor and following prescribed treatments strengthens your claim.
- Be Honest and Consistent: Make sure your statements to your doctor and insurer are consistent with your actual limitations.
- Respond Promptly to Requests: Failure to provide requested documentation may result in a claim denial.
Stay One Step Ahead of the Insurance Company
Receiving long-term disability benefits does not mean your claim is permanently approved. Insurers conduct periodic reviews to determine continued eligibility, and failing to meet their criteria can result in a termination of benefits. Understanding how these reviews work—and preparing for them—can help you protect your financial stability.
If your LTD benefits have been denied or terminated, the Ortiz Law Firm can help. We specialize in long-term disability appeals and lawsuits, representing claimants nationwide. Contact us online or call (888) 321-8131 today for a free consultation.
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