Long Term Disability: Information & Criteria

If you have a long term disability policy through your employer or you have an individual policy that you purchased on your own, you may be able to receive disability benefits to replace most or part of your salary if you are unable to work. Unfortunately, there is a lot of paperwork and red tape involved before you start to receive your benefits. Your LTD policy will outline important information like wait periods, disability definition, and the minimum number of working hours to qualify for benefits.

The Long Term Disability Claims Process

1. The first thing you should do is contact your employer’s human resources department for your disability insurance plan’s specific procedure details. Do not simply make this request verbally. Make the request in writing. Your disability insurance company should send you a written procedure or application for free.
2. Make sure you note any deadlines to file the claim.
3. File the claim before the deadline.
4. The insurance company may request additional information in order to make a determination on the claim. The insurer will advise you of any deadlines to submit the additional information. Remember it is your burden to prove you have a disability. It is not the insurance company’s burden to prove you are not disabled. Therefore, provide whatever documentation necessary to satisfy your “burden of proof.”
5. If you are approved, then you will start drawing your benefits. If you are denied, your insurance company should advise you of its decision in writing. If you received a denial, you have the right to appeal the decision.
6. Make sure to note any deadlines to file your appeal. The deadline is likely in the insurance company’s denial letter.
7. File your formal notice of appeal within the time limits, typically 180 days.
8. The insurance company will again review your appeal and will issue a new decision. If your claim is approved, you will begin to draw your benefits and any past-due benefits. If you are denied, then the insurance company should advise you of your appeal rights in the denial letter.
9. Once you have exhausted all of your administrative appeals, you have the right to file a lawsuit in federal court, challenging the insurance company’s wrongful denial of your claim.

What You Need to Prove to Receive Benefits From Your Long Term Disability Policy

The first thing you need to do is read through your LTD policy. You can pick up a copy of your plan from your employer’s human resources department. Sometimes human resource departments will try to delay providing you with this documentation. If you request a copy verbally or in-person and you do not get a response within 7-10 days, send a letter requesting a copy of your policy. If you are provided with a summary of benefits but the summary does not answer all of your questions, you need to request a copy of your full policy.

How Does Your LTD Policy Define “Disability”?

Every long term disability policy has a definition of what “disability” means to the insurance company. They are usually “totally disabled” which means you can no longer work at all and “partially disabled” which means you can no longer work full time in your current job. It is also important to know that your policy will outline exactly what they consider to be a disability, and your injury or illness must meet those minimum criteria to be eligible for benefits.

What are the Minimum Work Hours to Qualify?

In general, most LTD policies require you to work full-time (35 hours or more, or as otherwise defined in your policy) per week over a period of time. The exact working hour requirements will be outlined in your policy. Be sure that you have worked this minimum amount before applying for benefits.

What is the Waiting Period?

In most cases, the LTD policy will have a waiting period; sometimes called an “elimination period.” This is the period of time that you have to wait to receive benefits. For long term disability claims, this is between 90 and 180 days but check your policy for the exact number of days. You will also be required to exhaust your short-term disability before you can apply for long term disability.

Pre-existing Conditions and Exclusions

Under most LTD policies – if you have a pre-existing condition, you will not be able to receive benefits for that illness for the first year of your long term disability benefits. Some workplace illnesses and accidents are excluded from LTD policies. The use of alcohol and drugs or diseases caused by them are usually excluded as well. There is also a 24-month cap on long term benefits for mental health-related illnesses.

Proving Your Disability

The longest and most tedious process is gathering your data to prove your disability. After you read through your policy, you should be able to determine if you may qualify for LTD based on your insurer’s definition of disability. You will need to provide the claim adjuster with proof of your disability. This will include the opinion and notes from your treating physician, all lab and test results, x-rays, MRI scans, notes from doctors that have treated you, detailed surgical reports. This information will need to be gathered from all doctors that are treating you for your disability not just your primary physician.

It’s essential to include the complete and correct information on all your forms. Any missing or incorrect information can lead to a denial of benefits. Be sure to have your physician note symptoms that are not always measured with lab tests such as pain. Physicians are known for not documenting a patient’s pain level in their notes so be sure that they are documenting all your symptoms. It is important to make all your scheduled appointments and do not skip treatments or taking your medications while waiting on an LTD decision. If you miss appointments or do not take your medications, it will be a sign that you do not need treatment as you say you do; this could lead to a denial of services.

Legal Representation in LTD Claims

The process of applying for long term disability benefits can be tedious. The process involves a lot of gathering information and can be overwhelming to some. If you have questions, you may want to consult an experienced LTD attorney. Although based in Florida, the Ortiz Law Firm represents claimants across the United States.

If your LTD claim has been wrongfully denied or terminated and you’d like to speak to one of our Pensacola Long Term Disability Insurance Attorneys about your denied claim, contact us at (866) 853-4512 to schedule a consultation. We can help you evaluate your claim to determine if you will be able to access Long Term Disability Benefits and how to move forward with the process.