Today, we’re going to discuss the most important factors of your long-term disability (LTD) insurance claim.
When our office takes on a client who has a long-term disability insurance application or an appeal, we will evaluate several important factors right off the bat to help determine the best way to move forward with your claim.
Your Policy
The first critical step is determining what law governs your specific long-term disability insurance policy. These days, most LTD claims are governed by ERISA law. This law, called the Employee Retirement Income Security Act, governs nearly all LTD policies issued as part of your employee benefits package. However, if you purchased your LTD policy from an insurance agent or acquired it outside of work, there is a likelihood that your policy is governed by that state’s contract laws. Typically, you want the policy to be governed by state law because ERISA law severely limits your potential recovery and generally does not allow you to have a jury trial.
Definitions & Terms in Your Policy
There are several important things contained in your long-term disability policy. The first is how disability is defined. Every insurance policy will define disability, and your entitlement to a benefit payment, slightly differently.
For example, some policies grant disability benefits if you are unable to perform the job you had, while others require you to prove that you cannot perform any job. What’s commonly found, especially in ERISA long-term disability policies, is a hybrid approach where you are granted benefits for the first 24 months if you cannot do your own job, but then you have to prove the inability to do any job.
It’s also important to know what exclusions and limitations exist. For example, long-term disability policies often contain a pre-existing condition exclusion. There are also limitations to benefits granted due to specific impairments. For example, many policies limit disability payments to 24 months for conditions primarily caused by a mental illness. Knowing your policy’s exclusions and limitations is critical for maximizing any benefits you might receive from your insurance policy.
You also want to know in which state your policy was issued. For example, a large company headquartered in a state like California may have a provision that says the policy is issued and governed by the state laws of California, even though you are working for the company in the state of Ohio. This is important because California and several other states banned discretionary clauses in these insurance policies. If your attorney recognizes this, they can use that fact to turn the momentum in your case from the insurance company back to you.
Medical Records & Treatment
It may seem very odd that we have yet to talk about medical records, treatment, and your diagnoses until this point, but truly understanding your policy is much more important to grasp before you even begin looking at medical records.
Once we get to the point of diving into your records, a few key points should be evaluated. First of course, are your medical conditions and any test results supporting those diagnoses. But more important than the diagnosis itself is what limitations stem from your medical conditions.
In order to determine how you are limited, you need to review the statements you made to your doctors and your response to certain treatments. In most cases, having medical opinions from doctors is either very important or necessary. Sometimes, you may even need specific testing related to how you would perform in a work setting, which is called a functional capacity evaluation. These factors should be considered when reviewing medical records to support your LTD claim.
Your Job
A final factor that deserves significant consideration with your long-term disability claim is evaluating your occupation or job you had. This is especially critical with your application and when the definition of disability hinges on whether or not you can perform your own job. You want very specific information regarding the physical aspects of how you performed your job. Often this can be found in your company’s official job description, but sometimes needs to be supplemented.
Of course, every claim is going to have its own unique aspects. That is why it is so critical, especially if you have a long-term disability policy governed by ERISA law, to seek out and hire an attorney with considerable experience handling ERISA LTD claims.
