If you’re dealing with a long-term disability (LTD) claim, it’s important to understand the documents that govern your benefits. Two key documents you’ll likely encounter are the Summary Plan Description (SPD) and the policy (or full “Plan”). While they may sound similar, they serve different purposes and carry different legal weight.
What Is a Summary Plan Description (SPD)?
The SPD is a document your employer is required to provide under the Employee Retirement Income Security Act (ERISA). It’s designed to explain your benefits in clear, straightforward language.
The SPD typically includes:
- Who is eligible for benefits
- Benefit amount
- Maximum payment period
- An overview of limitations or exclusions that may affect coverage
Think of the SPD as a helpful guide or overview. It’s meant to inform employees of what the plan offers without requiring them to dig through complex legal language.
RELATED POST: What Is ERISA and How Does It Affect My Long-Term Disability Claim?
What Is the Full Insurance Policy or Plan?
The policy or Plan is the actual legal contract between the insurance company and the plan sponsor (your employer). This document contains the official terms that govern your LTD claim.
The full policy typically includes:
- Detailed definitions (such as what qualifies as a disability)
- How benefits are calculated
- The length and conditions of coverage
- Detailed exclusions, limitations, and offsets
- The insurer’s responsibilities and rights
- Appeal procedures and legal provisions
This is the document that ultimately determines what you are entitled to under the plan. Courts and insurance companies rely on the policy to evaluate LTD claims.
RELATED POST: The Growing Trend of 2-Year Limitations in LTD Insurance Policies
Why Does the Difference Matter?
Many claimants only receive the SPD at first and may assume it contains everything they need to know. But in reality, the SPD is a summary — not the full policy.
If your LTD claim is denied or you’re preparing an appeal, it’s crucial to have the full insurance policy. If there’s a discrepancy between the SPD and the full policy or Plan, courts usually give precedence to the policy or Plan.
Do You Need Both Documents?
Yes. It’s a good idea to request both the SPD and the full insurance policy from your employer or the plan administrator. You have the right under ERISA to receive these documents, and having both helps you:
- Understand your rights and obligations
- Verify deadlines and appeal procedures
- Catch any discrepancies or missing information
Can the SPD Be Used Against You in a Claim?
Not typically, but it can cause confusion. If an SPD misstates the terms of the policy, and you relied on that version in good faith, courts may consider that in limited cases. Still, the policy is generally considered the governing document.
What If You Can’t Get the Policy?
If you’ve requested the full insurance policy in writing and haven’t received it, that could be a violation of ERISA. Courts can impose penalties for failure to provide plan documents upon request. In some cases, this delay can affect your ability to file a timely or complete appeal.
Need Help Understanding Your LTD Coverage?
If your long-term disability claim has been denied, it’s important to understand exactly what your plan covers. The Ortiz Law Firm helps claimants nationwide review their LTD policies and appeal unfair denials. Call (888) 321-8131 to schedule a free case evaluation.
