If you cannot work for an extended period of time due to a medical or mental health condition, then you may be able to claim financial benefits via a long-term disability insurance policy. Such policies are typically offered through employers as part of your overall benefits package. If your employer does not provide this coverage, you have the option to purchase your own long-term disability (LTD) policy.
Understanding the specific criteria for eligible medical or mental health conditions can help you assess your options and take necessary steps to secure needed financial support.
If you are looking to file an LTD claim, or your claim was denied, consider reaching out to an experienced long-term disability attorney with Bross & Frankel. We can help ensure that you get the benefits that you are entitled to under the terms of your LTD policy. An attorney can help evaluate your LTD policy, analyze medical evidence and other supporting documentation, and suggest strategies to help bolster your claim before filing. If the insurance company tries to delay or deny a claim, your disability benefits lawyer will push back to protect your rights. If necessary, your LTD benefits lawyer will appeal a denial or termination, up to and including filing a lawsuit in state or federal court.
Medical Conditions That Generally Qualify for Long-Term Disability
When it comes to LTD benefits, qualifying medical conditions may include a myriad of physical and mental illnesses, along with serious bodily injuries. It is important to check with your insurance provider to determine what medical conditions are covered under the terms of your specific LTD policy.
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 claim for LTD benefits.
Some of the most common medical conditions that typically qualify for long-term disability coverage include:
- Cancer: Oncological disorders such as 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.
- Chronic illnesses (e.g., chronic fatigue syndrome, chronic obstructive pulmonary disease (COPD), chronic pain): 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
- Gastrointestinal disorders (e.g., Crohn’s disease): 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.
- Mental health issues (e.g., anxiety, clinical depression, bipolar disorder, post traumatic stress disorder, etc.): Various psychiatric conditions, including clinical depression, bipolar disorders, and schizophrenia, might be covered under LTD insurance.
- Musculoskeletal disorders (e.g., degenerative disc disease): According to data from the Council for Disability Awareness, musculoskeletal conditions are the most common reason for filing LTD claims. These LTD claims typically include difficulties with ongoing back pain, various forms of arthritis, and joint issues that result in persistent pain and physical limitations, making it difficult to engage in routine tasks and job responsibilities.
- Neurological disorders (e.g., multiple sclerosis, Parkinson’s disease, Alzheimer’s, dementia, etc.): LTD policies often cover nervous system conditions like epilepsy and Parkinson’s disease, which can lead to considerable functional limitations.
Please note that the list above is a general overview of certain types of qualifying health and medical conditions. There are other conditions that may qualify for LTD benefits, depending on the terms of your LTD policy.
How Eligibility for Long-Term Disability Benefits is Determined
Eligibility for long-term disability benefits is typically determined by multiple factors, including whether your medical condition meets the specific definition of a “disability.” It is also important to note that the burden of proof falls on you to substantiate that your medical condition fits the eligibility requirements outlined in your LTD policy.
The LTD insurance company will determine eligibility for benefits depending on whether your condition meets the policy’s specific definition of disability. How that term is defined in your policy will likely be based on your ability to work in your “own occupation” or “any occupation.”
“Own occupation” coverage typically defines disability as being unable to perform essential duties of your regular job. Your typical work duties are often based on how your job is defined in the national economy rather than by your specific employer. “Own occupation” coverage typically only lasts 24 months under the majority of LTD policies.
“Any occupation” coverage is typically triggered after 24 months. This type of coverage requires proof of your inability to perform the essential duties of any job or earn a specific percentage of your pre-disability income.
If deemed eligible, the majority of LTD policies typically pay out between 50 to 60 percent of your pre-disability wages in the form of monthly cash benefits.
Proof of Qualifying Disability
Claimants are required to provide their LTD insurance company with medical records and other evidence to substantiate their disability claim. Types of supporting evidence may include:
- Lab work
- Imaging (X-rays, CT scans, MRIs)
- Attending Physician statement(s) containing a specific medical diagnosis
- Testimony from colleagues to support your disability claim.
The insurance company 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.
Waiting Period to Access Benefits
It is important to understand that, once you become disabled, you generally cannot access benefits under your LTD policy for a period of time. This is typically referred to as a waiting period (also referred to as an elimination period). In most LTD insurance policies, the waiting period is most commonly about 90 days, but will vary depending on the specific policy. You must remain continuously disabled during the elimination period to be eligible for LTD benefits.
What Can Cause an LTD Claim to be Denied
There are various grounds an insurance company can try to use to deny an LTD claim, including:
- Insufficient evidence
- Ineligible medical condition
- Missing a deadline
- Errors on the LTD claim form
Your LTD insurance claim may also be denied if the company has reason to believe your medical condition has improved. It is important to carefully examine your benefits denial letter to understand the basis of the insurance company’s denial.
If your claim is denied, contact an experienced and knowledgeable long-term disability lawyer with Bross & Frankel for guidance on the best actions to take.
Considering an LTD Claim? We are Ready and Able to Help.
Long-term disability insurance is generally intended to serve as a safety net and provide a level of 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 balk at providing the coverage under the terms of the policy. This is where Bross & Frankel can help. 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.
In addition, it is quite common for long-term disability policies to contain provisions requiring you to apply for SSDI benefits. Why would your long-term disability policy require you to apply for SSDI benefits? The short answer is to allow your insurance company to offset your long-term disability benefits with the amount you may receive via SSDI. There are many intricacies in the interplay between long-term disability and Social Security disability, which is why hiring a law firm (like Bross & Frankel) that handles both types of claims may be to your advantage.
Based in Cherry Hill, Bross & Frankel represents people with disabilities throughout New Jersey and Pennsylvania as they seek disability benefits. We possess significant experience handling long-term disability claims and aggressively advocate for our client’s rights in each case. To learn more or to schedule a free claim review with a New Jersey long-term disability attorney, give us a call at 856-795-8880 or fill out our online contact form.