Last Updated: December 4, 2023 | Reviewed and Edited by: Ortiz Law Firm
If you have received a long-term disability claim denial, we may be able to help you file an appeal or lawsuit to recover your benefits. Since 2012, the legal team at Ortiz Law Firm has been committed to assisting individuals denied the long-term disability benefits they deserve. We can manage the legal intricacies, enabling you to concentrate on your well-being and family while we fight to obtain the benefits you deserve—call (888) 321-8131 for a free case review.Get a Free Case Review
Understanding Long-Term Disability Insurance
Long-term disability (LTD) insurance offers financial assistance to employees who can’t work for an extended time due to health issues, injuries, or accidents. This form of insurance allows employees to receive a percentage of their usual income while unable to perform their job duties, regardless of where the injury or illness occurred. Regrettably, some insurance providers might unjustly deny your LTD claim to increase their profitability.
Eligibility Criteria for Long-Term Disability Benefits
In broad terms, you could be eligible for LTD benefits if you:
- Obtain long-term disability insurance coverage.
- Have a qualifying medical condition and
- Submit an LTD claim to your insurance carrier.
“I was fighting a long-term disability company whose policy I had bought and who refused to pay any of my benefits after I became disabled. It turns out not many law firms will even consider taking a case with a private long-term disability company. Nick agreed to take my case and though there were many hoops he had to jump through, he never gave up. I will always be grateful to Nick and his staff for all the work they did on my behalf.” – Teacher in North Carolina with a Denied Disability Claim
Medical Conditions That May Qualify for Long-Term Disability
A wide array of medical conditions may qualify for long-term disability. These conditions and the necessary medical treatment can significantly interfere with an individual’s ability to obtain and maintain gainful employment, thereby making such individuals eligible for disability insurance benefits.
You must understand your insurance company’s definition of disability before submitting a disability claim. You can find this information in your insurance policy. It’s important for applicants to carefully review their policy’s terms and conditions to see if they qualify for disability benefits based on their specific medical condition.
For more information about the medical criteria for long-term disability benefits and how we can assist you in appealing a denied claim, don’t hesitate to contact us—call (888) 321-8131 for a free case review.
Categories of Medical Conditions for Disability
Below are some of the medical conditions that may be considered severe enough by disability insurance companies to qualify a claimant for long-term disability or individual disability insurance benefits. Most of these conditions fall under one of several categories.
Oncological disorders like cancer are among the leading causes of LTD claims. Patients dealing with cancer frequently undergo therapies such as chemotherapy and radiation, resulting in side effects that may impair their ability to work for a prolonged duration. During this challenging time, disability insurance can provide essential financial assistance. Many types of cancer may qualify you for benefits, including:
LTD insurance plans typically cover heart failure, ischemic heart disease, and cardiac arrhythmias if these issues significantly restrict one’s physical capabilities and performance at work.
Insurers may periodically reevaluate heart-related claims by requesting updated medical evidence several months after a cardiac event to reassess your ability to work. Common cardiovascular disorders include:
A chronic illness is a condition that persists and necessitates continuous medical treatment over time. Some conditions that are often chronic and may qualify for LTD benefits include:
At Ortiz Law Firm, we helped a client with chronic fatigue after Reliance Standard terminated the claim, citing a policy provision that limits payment of benefits for a disability caused by or contributed to by a mental or nervous disorder to 24 months. We appealed the denial, and the claim was reinstated!
Congenital Disorders Affecting Multiple Body Systems
Mosaic Down syndrome is the primary congenital disorder that may qualify for LTD benefits. Other inherited conditions that affect multiple systems within the body may also be considered eligible if they result in significant functional limitations and restrict routine activities. These conditions include:
- Non-mosaic Down Syndrome
- Trisomy X Syndrome (XXX Syndrome)
- Fragile X Syndrome
- Phenylketonuria (PKU)
- Caudal Regression Syndrome
- Fetal Alcohol Syndrome
A degenerative condition is a disease where an organ’s cellular and tissue makeup progressively decline. Examples of such conditions include:
Endocrine, Metabolic, and Nutritional Disorders
Conditions that disrupt hormonal balance, like diabetes, thyroid issues, and elevated blood sugar, may qualify for LTD benefits.
Digestive system disorders such as Crohn’s or liver disease can lead to incapacitating symptoms that may affect one’s ability to perform regular work duties.
Insurers generally assess how treatments influence the intensity and persistence of gastrointestinal conditions before confirming if a claimant is eligible for LTD benefits. Some digestive disorders include:
Under LTD plans, conditions affecting the kidney and urinary system that result in chronic kidney disease or complete renal failure may also be covered. Insurers consider related symptoms, complications, and related conditions when evaluating claims. Genitourinary impairments could include:
- Genital Organ Disorders
- Nephrotic Disorder
- Urinary Tract Infections
- Uterine Prolapse
Some blood-related conditions, such as severe anemia or clotting issues, could be covered if they significantly limit your ability to work.
Factors such as your symptoms, the effectiveness of your treatment, and medication side effects will be considered by your insurer when assessing your claim. Some hematological disorders that may qualify for long-term disability benefits include:
- Aplastic Anemia with Bone Marrow or Stem Cell Transplantation
- Chronic Anemia
- Chronic Granulocytopenia
- Sickle Cell Disease
- Chronic Thrombocytopenia
- Coagulation Defects and Hemophilia
- Hereditary Telangiectasia
- Liver Transplantation
- Polycythemia Vera
- Spleen Diseases
- Systemic Vasculitis
Immune System Disorders and Infections
LTD insurance might cover issues related to the immune system, often characterized as autoimmune disorders, immune deficiency disorders (excluding HIV), and HIV infection. These conditions can result in considerable physical limitations for the insured. Common autoimmune disorders include:
Various psychiatric conditions, including clinical depression, bipolar disorders, and schizophrenia, might be covered under LTD insurance. Insurers will thoroughly review your medical history and daily functions to ascertain eligibility. In extreme cases, these disorders may compromise one’s ability to hold a regular job. Several mental health conditions could qualify for long-term disability benefits, including:
Although these illnesses are severe, you must verify the existence of your illness and the resulting limitations. Proving the existence of your illness and the resulting limitations can be challenging. Policyholders should also be aware that many policies limit the benefit period for mental health claims.
Most LTD policies have a maximum benefit period of 24 months for mental health conditions. The insurance company uses the reasoning that these illnesses are difficult to prove with medical testing and lab reports so that they can be faked or exaggerated.
Request a free case review to see if a long-term disability lawyer at Ortiz Law Firm can help you pursue additional benefits beyond your policy’s mental health limitation.Get a Free Case Review
According to the Council for Disability Awareness, musculoskeletal conditions are the most common reason for filing LTD claims. These claims can include ongoing back pain, various forms of arthritis, and joint issues, resulting in persistent pain and physical limitations, making it difficult for people to carry out their usual job responsibilities.
Musculoskeletal impairments include:
- Avascular or Aseptic Necrosis (AVN)
- Back Pain
- Carpal Tunnel Syndrome
- Cervical Stenosis
- Chiari Malformation
- Degenerative Disc Disease
- Degenerative Joint Disease or other joint disorders
- Fracture of the Femur, Tibia, or Pelvis
- Fracture of an Upper Extremity
- Herniated Disc
- Inflammatory Arthritis
- Lumbar Stenosis
- Marfan Syndrome
- Mixed Connective Tissue Disease
- Muscular Dystrophy
- Pectoralis Major Injury
- Pelvic Floor Dysfunction
- Poliomyelitis (Polio)
- Complex Regional Pain Syndrome (CRPS), also known as Reflex Sympathetic Disorder.
- Rheumatoid Arthritis
- Ruptured Disc
- Soft Tissue Injury (Burns)
- Spina Bifida
- Spinal Arachnoiditis
- Spine Disorders
- Temporomandibular Joint Disorder (TMJ)
- Undifferentiated Connective Tissue Disease
LTD policies often cover nervous system conditions like epilepsy and Parkinson’s disease, which can lead to considerable functional limitations.
Reviewers will examine how your condition affects your physical and cognitive abilities and impedes your regular work activities. Some of the neurological disorders that may result in impairment include:
Conditions like COPD or severe asthma could qualify for LTD benefits. These respiratory issues can impair breathing and limit one’s ability to undertake physically demanding tasks. Respiratory disorders that may result in a disabling impairment include:
LTD benefits may be an option for those unable to maintain consistent employment due to acute and debilitating skin conditions. Factors like the size, location, and frequency of outbreaks are assessed. Common skin disorders include:
- Bullous Diseases
- Chronic Skin Diseases
Special Senses and Speech Impairments
Severe impairments affecting vision, hearing, or speech may also be eligible for LTD benefits. Such impairments can significantly affect one’s capacity to communicate and perform effectively in a work setting, making them eligible for disability benefits. These conditions may include:
Each policy has its own definitions of disability and different requirements that must be met for a condition to qualify for benefits. You should review the terms of your specific policy when determining whether your medical condition will be eligible.
Filing a Claim for Long Term Disability Insurance
Remember that insurance companies are vested in demonstrating that you don’t meet the criteria for receiving long-term disability benefits. Rest assured, they will request comprehensive information about your medical condition, including diagnostic tests, healthcare records, and any other pertinent documents.
Your insurance provider may even attempt to reject your long-term disability claim by inaccurately categorizing your condition or asserting that your condition is mental in nature when it is a physical disease. Fortunately, if your claim for disability benefits is turned down, Ortiz Law Firm may be able to assist you in challenging the decision.
“Ortiz Law Firm has done an amazing job keeping me updated on every step of the process, which helped relieve some of my stress. It was also tremendously helpful to no longer have to personally deal with the anxiety created by the constant bombardment of arguments and requests from the insurance company.”
– Analytics Consultant in Iowa with a Denied Disability Claim
Why Should I Hire a Long-Term Disability Lawyer?
Receiving a long-term disability claim denial leaves many individuals bewildered and disheartened by the time and effort it will take to challenge the insurer’s decision.
Engaging the services of an attorney specializing in long-term disability claims can be a tremendous relief. Not only can they advise you, but they can also manage the appeal for you, simplifying the legal process during an already stressful period.
Avoid jeopardizing your appeal by overlooking details or lacking crucial information. There is no reason to take this risk when firms like Ortiz Law Firm stand ready to assist you.
Click to call our Long Term Disability Lawyers today.
Challenging an Unjust Denial of Long-Term Disability Benefits
If you believe your disability claim was unjustly denied and you are eligible for benefits, don’t accept the rejection without question. It’s possible to appeal the insurer’s ruling and receive the benefits you rightfully deserve.
Since 2012, Ortiz Law Firm has helped clients nationwide recover their denied disability benefits. We have represented claimants in claims with New York Life, Lincoln Financial/Liberty Life, Reliance Standard, Prudential, The Hartford, The Standard, MetLife, Guardian, Unum, Sun Life, and various other disability insurance companies.
We can help you fight back against an unjust denial. To receive a free, no-obligation case evaluation, complete our online contact form or dial (888) 321-8131 today. Our experienced legal team will listen to your story and inform you about your legal rights.
Long-Term Disability Qualification FAQs
How do I know if I qualify for long-term disability benefits?
Examine the terms and conditions of your policy to see if you meet your insurer’s criteria for being classified as ‘disabled.’ If you suffer from a medical condition that qualifies as a disability, you should submit a claim to your insurance company.
If your claim is rejected, we may be able to help you obtain the benefits you deserve by guiding you through the appeal process. Contact us today to learn more about how we can help you.
What are the requirements to qualify for long-term disability?
To be eligible for extended disability coverage, you need to have a medically verified condition that inhibits your ability to work and aligns with the criteria for disability as outlined in your insurance policy. The criteria for eligibility and the conditions considered valid can differ depending on the insurance company. Therefore, it’s crucial to closely read and understand the stipulations in your specific policy to know what qualifies you for disability benefits.
What if I can only work part-time?
If your medical conditions prevent you from working full-time, but you can still work part-time, you’ll need to check your insurance policy to ensure benefits are payable for partial disability. The exact definition of partial disability will vary between policies. Some policies may not pay any benefits for partial disability. If you’re unsure if your policy includes benefits for partial disability, request a free case evaluation.
What medical conditions qualify for long-term disability?
Long-term disability usually involves health issues that lead to limitations affecting one’s capacity to perform occupational duties or everyday tasks. Every policy is different, and the severity of your condition is also a factor. However, the following conditions are generally eligible for disability coverage:
– Bipolar disorder
– Carpal tunnel syndrome
– Chronic fatigue syndrome (CFS)
– Crohn’s disease
– Degenerative disc disease
– Heart disease
– Herniated disc
– Multiple sclerosis (MS)
– Post-traumatic stress disorder (PTSD)
– Spine disorders
While both physical and mental health issues may qualify for long-term disability benefits, examining your plan is crucial to understand the conditions covered and any exclusions or limitations that may apply to your claim.
If you’ve been denied benefits, remember that you only have a limited time to initiate an administrative appeal. If you want to speak with our legal team, dial (888) 321-8131.
Will the insurance company obtain my medical records?
The burden of proof falls on the claimant. This means that you must show that your condition has impacted you in such a way that you are unable to work. You are expected to provide medical evidence to support your claim during the claims process.
Why are long-term disability claims denied?
Long-term disability claims can be denied for various reasons. Your insurer will be looking for any reason to avoid paying your claim. Some of the most common reasons for denial include:
– There is not enough evidence to support your claim.
– You did not file your application on time.
– You did not submit supporting medical evidence on time, and
– Your condition is considered pre-existing under the terms of the policy.
Can I appeal a long-term disability claim denial?
If your deadline to file an appeal has not passed, you can file an appeal. A claimant usually has 180 days to appeal a denied claim. You can contact our office to learn more about how to appeal.
What is the long-term disability appeal process like?
Typically, the appeal process includes your lawyer compiling proof to strengthen your case, submitting your appeal to the insurance provider, and serving as your legal advocate if your case proceeds to a hearing or trial. The steps might vary depending on whether your disability claim is subject to ERISA (Employee Retirement Income Security Act) regulations.
Our experienced legal team specializes in long-term disability denials. We can manage every phase of the appeal process for you, including evidence collection, submitting the appeal, or initiating a lawsuit.
How long will I receive long-term disability benefits?
Short-term disability coverage typically expires after a maximum of six months. In contrast, long-term disability insurance aims to offer protection over extended durations, often lasting for multiple years or until retirement.
Some LTD policies place a maximum payout duration on “non-verifiable” conditions, “self-reported symptoms” conditions, musculoskeletal disorders, and/or chronic illnesses such as arthritis, back pain, fibromyalgia, migraine headache disorders, and carpal tunnel syndrome.
Conditions associated with lifestyle choices like COPD from tobacco use, alcoholism, or other diseases related to drugs or alcohol use could result in termination of benefits after 24 months or less. Check your policy for limitations based on these types of conditions.
What is the leading cause of long-term disability?
According to the Council for Disability Awareness, the primary reason for long-term disability claims stems from conditions affecting the muscles and bones, such as back pain and arthritis.