At the end of the day, a long-term disability claim is governed by a contract. You, perhaps through your employer, but with an insurance company, have an agreement where if you’re unable to work they’re to pay you benefits under the disability plan. Most people, when they’re given this type of benefit through their employer, they receive what’s called a summary plan description, which is a booklet or a short three to four-page summary of your benefits. Now, this is not your actual policy or plan. This is just a summary of the types of benefits that you’re entitled to.
If you’re going to make a claim for long-term disability benefits, then you want that full policy. It is important to understand the key terms of a long term disability insurance policy in order to fully understand your coverage and ensure that you are getting the protection you need. Understanding the key terms of an insurance policy can help you understand what is and is not covered.
Understanding the key terms of an insurance policy can also help you navigate the claims process. Knowing what documentation is required, what your responsibilities are, and what to expect from the insurance company can help you successfully file a claim and receive the benefits you are entitled to.
How to Obtain Your Policy
What you need to do is request a copy of your policy. Note – this is different than the Summary Plan Description. It is much longer and much more detailed. The first place you can look to is the insurance company handling your case. So let’s say that you’re going through MetLife, Lincoln, or Liberty Mutual, you can contact that carrier and ask them for a copy of the policy. They may say, “We’re not the plan administrator. We don’t actually have a copy of the policy. You need to get that from the plan administrator.”
So who’s the plan administrator? That’s the person that administers the file, and it is in most instances, your employer. You may have to go back to your human resources department and ask them for a copy of the policy. Again, it’s extremely important that you get this so that you know what you have to prove in order to get benefits.
This request should be done in writing. Most people say, “Oh, I called them, and they said they would send me something, but I didn’t get anything.” You should put the request in writing, and then they’re on the clock to get you the plan within 30 days. If you don’t receive a copy of your policy within a reasonable amount of time, follow up with the administrator to ensure that your request is being processed. Under ERISA regulations, if they don’t provide the plan within 30 days, then they may be subject to penalties of up to $110 per day for their failure to produce the document.
Reviewing Your Policy
When reviewing a long term disability policy, it is important that you begin your review of the policy with a “higher level” view. In other words, you should start your review by looking at the policy as a whole as opposed to getting bogged down in the details. You can look at the specific details later once you come up with a specific strategy in pursuing or appealing the claim.
As you begin this review, it may be helpful to have some additional information at hand. This may include the denial letter; evidence of eligibility for other disability benefits like state disability benefits, Social Security Disability, or VA disability; a detailed job description; and any restrictions/limitations identified by medical providers.
Review and Calendar Any Deadlines
The very first thing you should do is note any contractual or statutory deadlines for your claim. Deadlines in a disability insurance claim can vary depending on the specific insurance policy. Here are some common deadlines that may apply:
- Filing a claim: This is commonly referred to as the “Notice of Claim”. There may be a deadline for filing a disability insurance claim after becoming disabled. This deadline typically ranges from a few months to a year, depending on the policy.
- Providing documentation: This is commonly referred to as the “Proof of Loss”. Once you file a claim, you may have a deadline for providing documentation to support your claim, such as medical records or proof of income.
- Appealing a denied claim: If your claim is denied, you may have a deadline for appealing the decision. This deadline can range from a few weeks to a few months, depending on the policy. Most appeal deadlines are 30, 60, 90 or 180 days after the date on the denial, or after receiving a notice of denial.
- Statute of Limitations for Court Review, or requesting an external review: If your appeal is denied and you have exhausted all mandatory administrative remedies, you may have a deadline for requesting a court review of the decision. This deadline can also vary depending on the specific language in the policy.
Here are some additional steps to review your long-term disability policy:
- Understand the key terms: Start by understanding the key terms in your policy, such as the elimination period, benefit period, and definition of disability. Make sure you understand what each of these terms means and how they apply to your coverage.
- Review the coverage: Look at the coverage details to see what is and is not covered under your policy. Make sure you understand what types of disabilities are covered, what benefits you are entitled to, and any exclusions or limitations.
- Verify the “effective date of coverage” under the policy. The effective date of coverage in a long-term disability (LTD) policy is the date on which the insurance coverage begins. This date is typically specified in the insurance policy and may be determined by a number of factors, including the date the policy was purchased or the date the premiums were paid. This is particularly important if the employer only recently purchased a new policy! In order to qualify for benefits, you would need to show that your disability began after the policy took effect.
- Check the benefit amount: Review the benefit amount to see how much you are entitled to receive if you become disabled. Make sure the amount is sufficient to meet your financial needs and consider whether you need additional coverage to fill any gaps.
- Review the waiting period: Check the waiting period or elimination period to see how long you will need to wait before your benefits start. Make sure you have a plan in place to cover your expenses during this waiting period.
- Understand the claims process: Review the claims process to understand what you need to do to file a claim and how long it may take to receive benefits. Make sure you have all the necessary documentation and know what to expect throughout the process.
- Review any changes: Check the policy for any changes that may have been made since the policy first took effect. Make sure you understand how these changes may impact your coverage and benefits.
Summary Plan Description v. Policy
A Summary Plan Description (SPD) is mandatory in a disability claim that is covered by the Employee Retirement Income Security Act (ERISA).
When you purchase new car insurance, typically, the first thing that they’ll send you is a summary of coverage often called a declaration page or a one to two-page letter that summarizes the types of coverages that you have. After that, typically, you are also given a thicker booklet that comes in the mail and might be 30, 40, or 50 pages long, and most of us just file it away. That’s your actual policy that details the entire contract.
The same thing occurs in a long term disability claim. The SPD is a written document that provides a summary of the key features of an employee benefit plan, including a long-term disability plan. It must be provided to plan participants and beneficiaries, and it includes information about how the plan works, what benefits are available, how to file a claim for benefits, and other important details. Underlying the summary is the actual plan or policy.
I can tell you that in most instances in a long term disability case, that policy is between 20 and 50, maybe even 100 pages long. It sets out what your rights are under the policy, it spells out the benefits that you’re entitled to, but perhaps most importantly, it also shows what your burden of proof is and what you have to show in order to get your benefits. That’s why it’s extremely important for you to get a copy of this. Most of our clients don’t have a copy of the policy when they call us.
Under ERISA, the SPD must be written in a clear and understandable manner, and it must accurately reflect the terms of the plan document. If there is a conflict between the SPD and the plan document, the plan document will generally control. If the SPD and the LTD policy conflict, then you want to determine which provision the insurance company relied on in issuing its determination. Again, the full LTD policy or plan should control over the SPD, but some court cases have ruled in favor of plan participants where they demonstrated that they reasonably relied upon a provision in the SPD.
In sum, that’s why it’s extremely important for you to get a full copy of your long term disability insurance policy. You can follow the process outlined above to obtain your policy. If you’ve been denied long term benefits, then I encourage you to give us a call at (866) 853-4512. Or, if you prefer to review some additional information, you can request a free copy of a book I wrote called the “Top 10 Mistakes That Will Destroy Your Long Term Disability Claim”.