The LTD Application and Determination Process

In this article, we walk you through the basics of the Long Term Disability (LTD) application and determination process.

Before you apply for long-term disability benefits, it is helpful to know how the process will work. After you have exhausted your short-term disability benefits (this is usually a requirement), you can apply for long-term disability benefits. With some insurance companies, a short-term disability benefits claim will roll over into a long-term disability insurance claim. However, with other companies, you may be required to submit a separate application for long-term disability benefits – even if the short-term disability claim is with the same insurance company!

How you file a long-term disability claim depends on the type of plan you have. If your policy is part of a group plan, you should contact your human resources manager to obtain a copy of your summary plan description and a disability claim application. If you purchased an individual disability policy, you should contact your broker or insurance agent for an application. Under either scenario, you can always obtain the necessary paperwork directly from the insurance company.

How to Apply for Long Term Disability Benefits

Step 1: Request a Copy of Your Long Term Disability Policy and Application From Your Employer

Usually, the human resources department can provide this with no problem. If they cannot, you need to request it in writing and send your request by certified mail. They are required to provide you with this information, and their failure to do so promptly can help your claim.

You may also be able to find the application on the insurance company’s website. Just be mindful when searching for it; make sure you are downloading the most recent application.

Step 2: Complete the Employee Statement Portion of the Application

You will complete this portion with the basic information like name, date of birth, address, family members, date of onset for your sickness or injury, the last date you worked, etc. You will also need to list your reason for applying for disability, the medical providers that are providing your treatment, your treatment plans, your medications, and any other form of income you have.

You will notice immediately that the form has limited space. This is intentional by the insurance company to deter you from providing everything you want so they can easily deny your claim. Just write or type out your responses and save a copy.

Step 3: Obtain Employer Statement From Your Employer

Your employer will also need to provide information to the insurance company. Typically your employer will provide your hire date, last date you worked, your earnings history, and your physical and mental job requirements. This can be completed by your human resources department or your payroll and benefits department.

Step 4: Obtain Statement From Your Physician(s)

The insurance company will require a statement from your treating physician(s) as well. They will request information such as: when you were diagnosed, details about your symptoms, pain levels, lab results, a list of limitations and restrictions, details about surgeries, and hospitalizations. If you receive treatment from multiple physicians you should try to obtain statements from each one.

We recommend that you make an appointment with your doctor and have them fill out the form while you are present. It is not uncommon for doctor’s offices to misplace paperwork or not treat it as a priority. This could delay your claim or even cause you to miss a deadline, which can cause an automatic denial. [Note: Most doctor’s offices will charge you a fee to complete this paperwork. It is totally within each doctor’s individual discretion (a) whether to charge a fee and/or (b) how much to charge.]

Step 5: Submit Additional Supporting Documents

A common mistake that people make is assuming that the insurance company will gather all the medical information themselves. While they will gather the majority, they will not gather additional documents that would support your claim. If you have documents that you think will support your claim, submit those as well. Just make sure it will not harm your case. Check out this article on harmful elements to be sure you don’t submit bad information.

Step 6: Review and Double-Check Your Application and Supporting Documentation

Before you submit your application, take some time to read through your application and make sure all the information is correct. The number one reason a claim is denied is due to missing or incorrect information.

Here are some examples of what to look for:

• Did your doctor note your pain levels on your forms?
• Are all your medications related to your disability listed?
• Did you write down the correct mailing address for your doctor’s office?

Step 7: Copy and Organize

After you double-check your application, make a copy of everything. Create a file or use a binder to neatly store all of your documents related to your disability claim. This will include all the letters from the insurance company, letters from your employer, your medical records, and a list of medications. Keep everything organized and make a copy of everything before you submit it.

Step 8: Bring a Claim to the Plan Administrator

Now that you have obtained all of the required documentation the next step is to bring a claim to the plan administrator. A claim is a

“request for plan benefit . . . made by a claimant in accordance with a plan’s reasonable procedure for filing benefit claims.”

29 C.F.R. §2560.503-1(e)

As set forth in Abdel v. U.S. Bancorp, 457 F.3d 877 (8th Cir. 2006), a claim for benefits is made when the claimant seeks benefits.  And to compare another case, Layes v. Mead Corp., 132 F.3d 1246 (8th Cir. 1998, wherein the court decided that there was no claim for benefits until formal procedures for filing a claim are satisfied.

Typically, an application for benefits consists of three parts:

1. An application with detailed information from the claimant;
2. Detailed information from the employer; and
3. The attending physician statement.

Failure to complete any of these forms can be fatal to a claim, so do not skip steps any of the steps outlined above.

In the case of Mitchell v. Equitable Life Assur. Soc’y of U.S., 310 Minn. 219, 224, 245 N.W.2d 618-620-21 (1976), the claimant was barred from filing suit for failing to supply the employee’s statement and physician’s statement.

There is also usually a requirement of a timely notice of claim and proof of loss or proof of claim consistent with your state’s insurance laws.  However, a late notice will usually only bar a claim where there is prejudice to the plan’s insurer. The notice prejudice rule that applies to an insured ERISA plan was set forth in UNUM Life Ins. Co. of America v. Ward, 526 U.S. 358, 369 (1999).

Sending your application by certified mail is a secure way of sending all these documents to your insurance company with the benefit of knowing for sure they received them. Save that mailing receipt as well.

The Determination Process for Long Term Disability Benefits

Most Long Term Disability insurance claims are initially processed by either (a) the insurance company itself; or (b) a claims administrator hired by the insurance company or employer to evaluate the disability claim. The “claimant” is the person who is requesting disability benefits.)

LTD insurance companies (or claims administrators) usually obtain applications for disability insurance benefits in person, by telephone, by mail, or by filing online. The application and related forms ask for a description of the claimant’s impairment(s), treatment sources, and other information that relates to the alleged disability.

The claims handler (also called a claims adjuster) is responsible for verifying non-medical eligibility requirements, which may include employment verification, a job description, salary information, and more.

The claims handler is responsible for making the initial determination on whether or not a claimant is disabled under the applicable long term disability insurance policy.

Usually, the insurance adjuster tries to obtain evidence from the claimant’s own medical sources first. If that evidence is unavailable or insufficient to make a determination, the adjuster may arrange for an “independent medical examination” to obtain the additional information needed.

Or the adjuster may have the claimant’s medical records reviewed by a “peer review physician”. The peer-review physician will then issue a report, which typically concludes that that claimant is not really that impaired.

After completing its development of the evidence, the disability insurance company or claims administrator will issue its disability determination.

If the claims handler found that the claimant is disabled, the insurance company completes any outstanding non-disability development, computes the benefit amount, and begins paying benefits. If the claimant was found not to be disabled, the insurance company issues a denial letter (or cutoff letter), and the file is administratively closed in case the claimant decides to appeal the determination.

 At this point, your next step is to exhaust all mandatory administrative appeals. Most long-term disability insurance policies/plans have an internal appeal process, whereby you have the right to file an appeal of a denial directly with the insurance company. This right becomes a duty if you want to file a lawsuit. That’s because in most cases you cannot file a lawsuit unless you have gone through all mandatory appeals directly with the insurance company.

If you have a group policy then your claim is likely governed by ERISA. The key to an ERISA disability benefits claim is to make sure to follow all required steps in the administrative process.  Claimants must “exhaust” their administrative remedies before filing a lawsuit.  Failure to exhaust one’s administrative remedies may result in significant limitations on the standard and scope of court review in a lawsuit.  This is why everything you do in the administrative claims process may determine whether you are ultimately successful in your claim should you have to go to court.

Most LTD policies have one of the following appeal structures: (1) two mandatory appeals; (2) one mandatory appeal; or (3) one mandatory and one “optional” appeal.

Consider Using an Experienced Disability Attorney

If you are unsure about how the long-term disability process works, consider using a disability attorney. Using an experienced disability attorney will help you protect yourself against the insurance company. The Ortiz Disability Law Firm is based in Florida but represents claimants across the country. Receive a free consultation by calling (888) 321-8131 with no obligation. We can help you evaluate your claim to determine whether you qualify for Long Term Disability Insurance Benefits under your policy and how to navigate the appeals process.