What Happens After You File a Claim for Long-Term Disability Benefits

Deciding that you can no longer work because of a long-term disability is only the first step to what can seem like a very long process. Find out what happens after you file a claim for long-term disability benefits, and how soon you can expect to start receiving benefits.

This blog post will review the steps that come after you file a claim for long-term disability benefits. It will discuss the insurance company’s investigation, medical examinations you may need to attend, and documents you may need to provide. It will also explain the deadlines placed on insurance providers to make a decision about your claim, and what you can do if the insurance company denies your long-term disability benefits claim.

Investigating Your Initial Claim for Long-Term Disability Benefits

When you apply for long-term disability benefits from your employer-provided insurance plan, you usually won’t be working with anyone at your job, although in some cases at large companies, an HR representative may coordinate the filing of the initial application before passing the claim off to the insurance company.  Therefore, you may have already discussed your claim with HR. However, these claims are typically processed by the insurance company itself. It is up to an insurance company adjuster to review your claim and confirm the amount for your monthly benefit, or deny your claim. But how does the adjuster make that decision? What happens behind the scenes after you file a claim for long-term disability benefits?

Your initial claim for long-term insurance benefits will set off an investigation to determine if you fall within the rules of your policy. Remember, the insurance agency is a for-profit company looking for any way it can find to say no to your request for benefits. They aren’t going to take your word for it that you are disabled. Instead, after you file a claim for long-term disability benefits you should expect the insurance company to:

• Review your employment records
• Request production of all your medical records (not just those connected to your disability)
• Interview neighbors and coworkers
• Use undercover surveillance of you at home or while you are out in public
• Review any claims for social security disability insurance or Workers’ Compensation
• Require you to attend “independent medical examinations” by their own doctors
• Request summaries or contact with your doctors and other medical providers
• Schedule a phone or in-person meeting with a field investigator

All this may feel invasive, and sometimes insurance companies can cross the line into illegal or at least unethical invasion of personal privacy. However, many long-term disability insurance policies require the applicant to cooperate with the investigation and comply with all requests for information. If you wrongfully refuse, it could cause your claim to be denied.

Appealing a Denial of Claims

Being uncooperative is hardly the only reason a claims adjuster could say no. After you file a claim for long-term disability benefits, the insurance adjuster could deny your request because he or she claims:

• You aren’t actually disabled
• You are disabled, but you can still do your job
• You aren’t receiving the right treatment for your disability
• You could do some other job, even with your disability (this usually comes up after a set period of time)
• Your condition is the result of a pre-existing condition
• You can’t prove that you are medically prevented from doing your job

If your insurance policy is covered by the Employee Retirement Income Security Act of 1974 (ERISA) (most employer-provided policies are), you have the right to know the reason your claim was denied, access to your entire file, and an opportunity to respond to any findings by the insurance adjuster or the medical examiner before the final decision is reached.

You also have the right to have that decision reached within a reasonable amount of time. The insurance adjuster has 45 days to respond after you file your claim for long-term disability benefits. He or she can request one extension of up to 45 days. That means you should have an answer within 3 months, unless it takes longer for you to gather information requested in the request for extension.

If you believe you were wrongfully denied benefits, or if the insurance adjuster takes too long to make a decision, you can contact a long-term disability attorney for help to sue the insurance company for wrongful denial. Except in cases of undue delay, you do have to go through your insurance policy’s appeals process first, so be sure you review the language of your policy carefully to protect your rights.  

Eligibility Reviews After You File a Claim for Long-Term Disability Benefits

The insurance company’s investigation can continue even after you have been approved for long-term disability benefits, in the form of an eligibility review. This will look a lot like the information gathering that happened after you first filed your claim for long-term disability benefits. The insurance company may contact you for updated medical records, income and work documents, and functional capacity testing. It may also require you to provide decisions on any application for social security disability reached after your initial benefits decision was reached.

An eligibility review can happen at any time unless your policy limits the timing or frequency. However, is most likely to happen when the test for disability changes. Most ERISA long-term benefits policies include two time periods. During the first, you are disabled if you are no longer able to your specific job. This can often last about 24 months. After that, the insurance company is only required to continue to pay benefits if you are disabled from working in any occupation. When you hit that 24 month mark, you can expect that the insurance company will initiate an eligibility review to see if your condition meets the new, more narrow standard for disability.

This decision can also be appealed to the court, so just like after the initial claim, it is a good idea to contact a long-term disability attorney when you believe you are under eligibility review. By working proactively, you and your attorney can document your continued disability, and keep your benefits in place. If you need help before or after you file a claim for long-term disability benefits, the attorneys at Bross & Frankel are here to help. We will review your claim, condition, and any denial or request for information, helping you protect your rights and your claim. Contact us or call us today at 856-795-8880 for a complimentary consultation.