Gastroparesis is a disorder in which the spontaneous movement of the muscles (motility) in one’s stomach does not function normally. Also known as delayed gastric emptying, gastroparesis is a medical condition that prevents the body from moving food from the stomach to the small intestine.
The effects of gastroparesis can be severe and may be unpredictable from day to day. Because of this, an individual suffering from gastroparesis may find that his or her symptoms make it impossible to continue working. If this individual has long-term disability benefits, then he or she may be eligible to collect LTD benefits.
Definition of Disability
Long term disability benefits are intended to provide financial assistance to individuals with long-term health conditions. Although Gastroparesis is not typically thought of as a totally disabling medical condition, applicants with this condition may be able to receive benefits if they meet the LTD policy’s definition of disability.
This definition of the term “disability” or “totally disabled” is defined in each LTD insurance policy. You should review your own policy to determine your specific definition. A sample definition states:
“Total Disability or Totally Disabled means that during the first 24 consecutive months of benefit payments due to Sickness or Injury:
- You are continuously unable to perform the Material and Substantial Duties of Your Regular Occupation, and
- Your Disability Earnings, if any, are less than 20% of Your pre-disability Indexed Monthly Earnings.
After the LTD Monthly Benefit has been paid for 24 consecutive months, Total Disability or Totally Disabled means that due to Injury or Sickness:
- You are continuously unable to engage in any Gainful Occupation, and
- Your Disability Earnings, if any, would be less than 20% of Your pre-disability Indexed Monthly Earnings.”
If you do not meet your LTD policy’s definition of “Total Disability” or “Totally Disabled”, it is not likely that you will be approved for benefits. However, if you do meet policy’s definition, you will be further evaluated based on specific technical and medical requirements.
It is important to note that applicants should inform the long term disability insurance company of any and all health conditions that they have. This means that if your gastroparesis is caused by another condition or you have another serious medical condition in addition to gastroparesis, you should inform the insurance company. This is due to the fact that the insurance carrier will evaluate you based on the combined effects of all conditions that you may have. For example, someone with gastroparesis alone may have his or her application denied. However, if the same person has diabetes and gastroparesis, he or she may stand a better chance of approval.
To be able to qualify under a medical vocational allowance, you will be evaluated based on your ability to perform work related activities. To do this, the insurance company will send your medical records to an “independent medical examiner” who will review your records and give a Residual Functionality Capacity (RFC) assessment. The RFC will determine what type(s) of work you can be expected to perform. Depending upon the results of your RFC, you will either be awarded benefits or recommended to return to work.
Beginning Your Application
As you begin the application process, you should collect extensive medical and non-medical documentation to support your claim. Medical documentation includes the medical records that serve as proof of your illness or disability. Without sufficient medical documentation, the insurance company will likely deny your claim for disability benefits. If you want to be really proactive, you should work with your doctor to collect copies of the following:
- Record of your diagnosis or diagnoses.
- A history of hospitalizations and/or medical appointments.
- The findings from physical and mental examinations.
- A history of any treatments you have received and your body’s response to these treatments.
- Lab results.
- A written statement from your doctor outlining your condition and the limitations that it causes you to experience.
- Non- medical documentation may include financial records, employment records, and various forms of identification.
Once you are ready to begin your application, you will need to fill out several forms your insurance company or employer will provide to you. Be sure to answer all questions completely and accurately. Your application should provide the insurance company with an understanding of your condition and the daily limitations that it causes. Any missing or inconsistent information could cause your application to be unreasonably delayed or even denied.
Receiving a Decision
The standard LTD application is processed within several weeks to several months. If your claim is denied, you may appeal the decision. Your denial letter should identify any time-limits for the appeal, but you should work diligently to file the appeal in a timely manner.
Although it can be discouraging to receive a denial, the appeals process is your chance to correct any mistakes in your application and provide further medical evidence to support your claim. It is important to note that many LTD applicants are approved during the appeals processes.
If you have gastroparesis and your long term disability claim has been denied or terminated, call the Ortiz Law Firm for a consultation at 850-308-7833.