In a perfect world, anyone who suffers from a physical or emotional disability would have the resources to seek treatment and provide for themselves without supplemental income. But since we live in the real world, many people struggle with how to make ends meet during a period when they are disabled. Long term disability insurance is supposed to provide supplemental support for you, but insurance companies like to make it difficult for claimants to get approved.
Under most long term disability insurance plans the insurance company has the discretion to interpret plan provisions. What that means is they have the right to review your case to determine whether you have satisfied the definition of disability. The long term disability insurance company does have the right to deny your claim.
The approval rate for initial claims is actually pretty high, but staying “on claim” and continuing to receive LTD benefits is much more difficult. Benefits may be granted at first, but a poorly prepared application for benefits may cause your claim to be terminated in the future.
Harmful Elements on Your Application
Claims are often denied because you did not provide sufficient evidence for approval. This is why it is so important to double-check everything before you submit it. Did you provide the correct doctors’ names and addresses? Did you provide the correct dates of service? The majority of claims are denied due to simple mistakes that can lead to months of frustration for you. Some insurance companies will try to point out “bad facts” that are on your medical record. This could be drug abuse, alcoholism, working after you say your disability started, or a doctor notating that you are exaggerating your claim. If you feel that bad facts such as these are hurting your claim, contact the Ortiz Law Firm and let us help you.
Communicating with the Insurance Company
The best way to communicate with the insurance company is in writing, on paper. You should limit the number of communications you have with the insurance company on the phone, for the exact reasons that brought about the topic of the video above. That is, oftentimes the insurance company won’t summarize what you said correctly in their letters to you. If the insurance company is calling you asking you for additional information or questions, we recommend that you ask them to put those questions in writing. Then respond to those questions in writing either in a letter, by fax, or potentially by email.
You should make sure that your letters are consistent with your limitations. So for example, if you have carpal tunnel syndrome and you have difficulty holding on to things, and you write a really long letter in longhand, you should indicate to them how long it took you to write the letter. Or if someone helped you write the letter, tell them that in your letter.
If the insurance company tells you something, and it’s something that’s beneficial to you, you should confirm that in writing. For example, if the insurance company adjuster told you, “We’re not going to be looking at your file for another year. We’re just going to pay you benefits for the next 12 months without further review,” then you should write a letter to the insurance company confirming that communication and saying, “This confirms that we talked and you said you wouldn’t need to review my file for another year.” All too often people do not confirm things in writing when they communicate with the insurance company.
You May Be Under Video Surveillance
It is common for the insurance company to put you under video surveillance during your claim process. Investigators are hired by the insurance company to stake out your house and take photos of you coming and going, moving around outside your home. The goal is to catch you doing something you aren’t supposed to do, like lifting a heavy bag of trash or cutting your grass. Be sure to follow all the limitations your doctor gives you even if that means your grass grows tall or your trash has to pile up for a while. Don’t overexert yourself.
We have some tips to improve your chances of being approved and continuing to receive benefits unless or until you are able to return to work:
Tip #1: Read Your Policy
Whether you have an individual policy or you are part of a group policy through your employer, you should read through your policy very carefully. If you do not already have a copy of your long term disability policy, go to your human resources department, and request a copy. By law, your employer must provide you with one. The best practice would be to request it in writing so your human resources department will not procrastinate in providing you a copy. Spend time reviewing your policy.
In the policy, you will see the exact terms and procedures you must follow during the claims process. Pay close attention to the deadlines written in your policy (Some policies state that you must file your disability claim within 30 days of the injury.)
Tip #2: Familiarize Yourself With Claim Forms
It’s smart to familiarize yourself with the claim forms before submitting your claim. The language can be tricky, but some of the things that will be requested are:
- Employee statement;
- Employers’ statement;
- Authorization to obtain medical information from your doctors; and
- Your doctors’ statement.
There may be additional documents required, so check your policy. Many claim forms do not leave enough room to write a complete statement. This is a tactic used by insurance companies to limit your response, but you have the right to attach additional sheets of paper to your statement. Just be sure to keep a copy and include page numbers at the bottom in case some pages get separated. Ex. (Page 1 would say “1 of 5”, page 2 would say “2 of 5”, etc).
Tip #3: Understand the Link Between Short Term Disability and Long Term Disability Policies
Check to see the connection between your short term and long term disability policies. Most insurance companies will require that you exhaust all of your short term disability benefits before you can apply for or otherwise qualify for long term disability insurance benefits.
Tip #4: Understand the Structure of Your Policy
Two types of periods govern most policies. The initial period (the first 24 months) and the continuation period (after the first 24 months). During the initial period, you will be disabled under “own occupation”. This refers to being unable to perform your current occupation. During the continuation period, you will have to be disabled under “any occupation,” which is just harder to prove than the initial “own occupation.” Claims that are considered a mental illness are terminated after 24 months with no continuation period. Benefits will also end if you reach retirement age during the claim period.
Tip #5: Check Your Policy For Medical Exclusions
When reviewing your policy, check for medical conditions that may exclude you from receiving benefits. Some of these issues are:
- Mental disorders;
- Pre-existing conditions;
- Diseases related to drug or alcohol abuse; and
- Impairments based solely on the patient’s complaints without medical evidence.
Tip #6: Make Your Doctor Aware of Your Intention to File for Disability
Your doctor will be your ally when it comes to your long term disability claim. Let your doctor know early on that you plan to file for long term disability if possible so they can prepare your case file properly. Most doctors have experience with patients who filed for disability benefits. They will know that even more information will be required to prepare for your claim. Information like:
- Comprehensive medical documentation of your diagnosed condition;
- A functional assessment completed by your doctor that outlines your limitations; and
- Detailed notes taken during routine visits to document your pain, daily life struggles, and mental health conditions caused by your disability.
Tip #7: Log All Communication Regarding Your Claim
Deadlines are extremely important when it comes to long term disability claims. Missing a deadline means you will not be able to file a case against the insurance company in administrative court. To avoid this, create a way to manage all your communications. Copy and save any communications that you send your employer, doctors, and the insurance company. Keep a journal to log telephone calls between you and the insurance company, doctors’ offices, and your employer. Remember to include: When (date and time), who you are speaking with, how they communicated with you, and what the conversation was about.
Here is an example: Brian had an appointment to see his neurosurgeon to discuss his Parkinson’s disease and the major symptoms that have impaired his ability to work. He had an appointment scheduled for over a month when the office calls and asks if the doctor could reschedule for another two weeks. Brian noted in his notebook that “8/9/2018 at 9:46 am Margie called from Dr. Brown’s office to reschedule his appointment for 8/24/2018 because Dr. Brown is going out of town on a ski trip with his family.” This journal entry helped prove that Brian has been keeping his appointments when the insurance company claimed he has been postponing them.
Tip #8: Gather Your Medical Records
Ideally, you want to gather your medical evidence before you submit your initial claim. This may not be possible before your window to file for long term disability closes. But you will likely need to go through the appeals process, so gathering them after submitting your initial claim will be okay. When gathering documents to submit for your claim, try to only gather the documents that are relevant to your case. Any additional records about previous injuries or illnesses may be used by the insurance company to say you have a previously existing condition and deny your claim.
Do not wait to start gathering your medical records. You will need to request copies from all the professionals that you are seeking treatment. The records departments at doctor’s offices are usually handling other day-to-day tasks, which means your records request may take weeks to receive. Expect to pay for your copies. Most doctors’ offices charge for records.
Do not stop gathering your medical records. As you continue to see your doctors for treatment, request copies of the latest information to add to your medical file. Request a “Summary of Visit,” which can help you remember all the tests that we conducted during the visit.
Tip #9: Don’t Be Discouraged By A Denial Letter
You can still be denied even if you do everything to put together a great claim. Most claims are denied the first time. The insurance company hopes that you will become discouraged and give up. Just remember when your claim is denied that you will have a limited time to file an appeal (usually 180 days).
Tip #10: Work With a Long Term Disability Attorney
The experienced disability attorneys at the Ortiz Law Firm can help you through every step of the process, from appeals to a potential lawsuit. They only get paid if you win your case. You can seek help without worrying about upfront costs or unexpected bills. Our law experts will focus on your case so you can focus on your illness.
We offer free consultations with no obligation to use our firm. We will review your case and answer any questions you may have. The Ortiz Law Firm has successfully represented people in disability cases across the United States. To see how we can help you win your long-term disability case, call us at (888) 321- 8131.