Are There Any Medical Conditions That Automatically Qualify For Long-Term Disability Benefits?

Navigating the long-term disability benefits application process can be intimidating, especially when dealing with a serious medical condition. A common question asked by individuals is whether there are any medical conditions that “automatically” qualify for long-term disability benefits. The answer is that “automatic” approval is not a concept used in practice when insurance companies assess an LTD benefits application. This is because benefits eligibility depend primarily on how a particular health condition impacts your ability to work. 

Nevertheless,  there are certain medical conditions that are commonly accepted by LTD insurance providers, such as advanced cancers, severe cardiovascular or neurological disorders, and multiple system impairments. Generally speaking, a qualifying medical condition must be serious enough to prevent you from working for an extended period of time. In addition, you must provide sufficient medical evidence to substantiate your LTD benefits claim.

Understanding Long-Term Disability Benefits

By way of background, long-term disability benefits provide financial support to individuals who cannot work due to medical conditions that are expected to last at least one year or result in death. Disability benefits can come from different sources, including Social Security Disability Insurance (SSDI), private insurance policies through employers, or individual disability insurance plans. Each program has specific criteria and definitions of disability, but certain severe medical conditions consistently meet the qualifications across different benefit systems.

The Difference between Social Security’s Listings / Compassionate Allowance and Long-Term Disability Claims

The Social Security Administration recognizes that certain medical conditions are so severe they automatically meet their disability standards. In addition, the Compassionate Allowances program identifies these conditions to expedite the approval process, often processing claims within days rather than months. This program covers more than 200 conditions, including various cancers, genetic disorders, and neurological conditions.  There is no equivalence in most long-term disability insurance policies for automatic conditions like this.  Although some policies may provide “catastrophic loss” or enhanced benefits, or sometimes, a streamlined process if certain conditions are met, these are specific to a policy and can’t be generalized.  Still there are a number of conditions that may be more likely to result in an award of LTD benefits. 

Cancer-Related Conditions

Many forms of cancer qualify for long-term disability benefits, particularly those that are advanced, metastatic, or have poor prognoses. Pancreatic cancer, regardless of stage, typically qualifies due to its aggressive nature and limited treatment options. Advanced lung cancer, including small cell lung cancer and non-small cell lung cancer that has metastasized, also have a higher likelihood of approval.

Leukemia in its acute forms, such as acute lymphoblastic leukemia and acute myeloid leukemia, qualifies for immediate benefits. Brain cancers, including glioblastoma multiforme and other malignant brain tumors, are recognized as automatically qualifying conditions due to their impact on cognitive and physical functioning.

Other potentially qualifying cancers include advanced liver cancer, metastatic breast cancer, esophageal cancer, and certain rare cancers like mesothelioma and angiosarcoma. 

A critical factor is typically the stage of the cancer and its expected impact on the individual’s ability to maintain substantial gainful activity.

Neurological Disorders

Several neurological conditions often qualify for long-term disability benefits due to their progressive nature and significant impact on daily functioning. Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease, is perhaps the most well-known automatically qualifying neurological condition. This progressive motor neuron disease leads to muscle weakness, paralysis, and eventual death, making it impossible to maintain employment.

Huntington’s disease, a hereditary degenerative brain disorder, also qualifies automatically once symptoms become apparent. Early-onset Alzheimer’s disease, typically diagnosed before age 65, is likely to receive approval due to its rapid cognitive decline and impact on functioning.

Other qualifying neurological conditions include certain forms of muscular dystrophy, particularly Duchenne muscular dystrophy in children, and various forms of spinal muscular atrophy. These conditions cause progressive muscle weakness and degeneration that severely limits physical capabilities.

However, unlike Social Security benefits, many LTD policies may intentionally limit benefits for some other conditions, such as mental health, or neurological conditions that are primarily diagnosed based on clinical symptoms rather than by objective findings, like fibromyalgia or chronic fatigue syndrome.  While few policies will preclude these conditions, many will limit benefits to 24 months or place other restrictions on an award due to these difficult-to-assess conditions.  It’s important to review your policy before making a decision about applying. 

Cardiac and Pulmonary Conditions

Severe heart and lung conditions may qualify for long-term disability benefits when they significantly limit an individual’s capacity for physical exertion. Advanced heart failure with an ejection fraction of 30 percent or may qualify, particularly if your “regular occupation” is strenuous.  

Chronic pulmonary conditions such as idiopathic pulmonary fibrosis, a progressive scarring of the lungs, automatically qualify due to their impact on breathing and oxygen exchange. Cystic fibrosis, a genetic disorder affecting the lungs and digestive system is also capable of preventing work and leading to an approval of benefits, especially when it reaches advanced stages.

Genetic and Chromosomal Disorders

Many genetic conditions qualify for long-term disability benefits, particularly those that significantly impact cognitive or physical development. Down syndrome in adults may qualify depending on the level of intellectual disability and associated health complications.

Trisomy 18 and Trisomy 13, chromosomal disorders typically diagnosed in infancy, automatically qualify due to their severe developmental impacts and life-limiting nature. Various genetic metabolic disorders, such as Tay-Sachs disease and Niemann-Pick disease, also receive automatic approval.

Immune System Disorders

Certain severe immune system disorders are likely to qualify for disability benefits. Advanced HIV/AIDS with specific complications or CD4 cell counts below certain thresholds typically receives automatic approval. Severe autoimmune conditions like systemic lupus erythematosus or rheumatoid arthritis may qualify when they cause significant organ involvement or functional limitations.

Mental Health Conditions

While mental health conditions rarely receive automatic approval, certain severe cases may qualify for LTD benefits. However, mental health conditions are almost always limited to a period of 24 months of lifetime benefits by most policies.   If your claim is primarily based on mental health it is important to review your policy carefully. 

Proof of Qualifying Disability

If you have one or more of the conditions described above, it is important to remember that you need to provide your LTD insurance company, or an SSDI administrator, with sufficient medical documentation and other evidence to substantiate your claim. 

Types of supporting evidence typically include the following:

• Attending Physician statement(s) containing a specific medical diagnosis 
• Testimony from colleagues to support your disability claim.
• Lab work
• Imaging (examples include X-rays, CT scans, MRIs)

The LTD insurance carrier may also request that you participate in a Functional Capacity Evaluation (FCE) or an Independent Medical Examination (IME). If you are asked to engage in an FCE or IME, contact a long-term disability lawyer with Bross & Frankel right away. These tests typically favor the insurance company and not you, the claimant.

Have Questions About Whether Your Condition Qualifies for LTD Benefits? Contact Bross & Frankel Today

LTD benefits are typically intended to serve as a safety net and provide a level of financial protection in the event that something goes wrong – like getting into a serious car accident or developing a chronic medical condition. Too often, however, insurance companies are inclined to swiftly reject LTD benefits applications. This is where Bross & Frankel can provide assistance. 

Our long-term disability benefits law firm will help level the playing field with the insurance company. We will work tirelessly and aggressively to help you get long-term disability benefits. To learn more about your legal options, give us a call at (856) 795-8880 or fill out our online contact form.