Living with a long-term medical condition that prevents you from working can be incredibly challenging. It often involves managing physical pain and discomfort along with emotional and financial stress from not working. 

Long-term disability (LTD) insurance offers much-needed financial support if you can’t work due to a qualifying medical condition. Having to prove your medical condition meets the criteria for disability insurance benefits adds another layer of complexity to an already difficult situation. Understanding what medical conditions are covered by your insurance policy is the first step to securing the critical support you need.

In this article, we’ll outline some medical conditions that typically qualify for long-term disability and share essential information on how to obtain benefits. 

We urge you to also consult an experienced long-term disability lawyer for advice on your claim. Having qualified legal guidance will significantly improve the chances of receiving the LTD benefits you deserve.

What we’ll cover:

What medical conditions qualify for long-term disability?

Qualifying medical conditions for long-term disability benefits may include a wide range of physical or mental illnesses or serious injuries. It’s important that you check with your provider to determine what medical conditions are covered under your specific policy.

Generally speaking, your medical condition must be serious enough to prevent you from working for an extended period of time. Additionally, you must provide sufficient medical evidence to prove it.

Here are some of the most common medical conditions that qualify for long-term disability:

  • Cancer
  • Chronic fatigue syndrome
  • Chronic obstructive pulmonary disease (COPD)
  • Chronic pain
  • Crohn’s disease
  • Degenerative disc disease
  • Diabetes
  • Heart disease
  • Long COVID
  • Mental health issues (e.g., anxiety, clinical depression, bipolar disorder, etc.)
  • Musculoskeletal disorders
  • Neurological disorders (e.g., multiple sclerosis, Parkinson’s disease, Alzheimers, dementia, etc.)
  • Post Traumatic Stress Disorder (PTSD)
  • Stroke
  • Traumatic brain injury

How is eligibility for long-term disability benefits determined?

Eligibility for long-term disability is determined by a combination of factors, including whether your medical condition meets the definition of a disability. The burden of proof is on you to demonstrate that your medical condition fits the specific eligibility requirements outlined in your policy.

Definition of disability

Your insurance company will determine eligibility for benefits depending on whether your condition meets the policy’s definition of disability. How disability is defined in your policy is typically based on your ability to work in your “own occupation” or “any occupation.”

  • Own occupation: “Own occupation” coverage 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. This coverage typically only lasts 24 months under most policies.
  • Any occupation: After 24 months, disability coverage typically shifts to “any occupation.” 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. This is the type of limited coverage that Social Security Disability Insurance (SSDI) provides.

Clearly, under most long-term disability policies, it becomes much more challenging to qualify for benefits after 24 months.

Proof of disability

You must provide your insurance company with medical records and relevant evidence to support your disability claim. Your insurance policy will typically outline the claim-filing requirements under a section often titled “Proof of Claim.

Supporting evidence may include  lab work, imaging (X-rays, CT scans, MRIs), and an Attending Physician Statement that provides a specific medical diagnosis. If possible, you could also gather testimony from colleagues to support your disability claim.

The insurance company may request that you participate in a Functional Capacity Evaluation (FCE) or an Independent Medical Examination (IME). In this case, you should contact a long-term disability lawyer immediately. These tests typically favor the insurance company, not the claimant.

Elimination period

Long-term disability insurance policies typically include a waiting period, known as the elimination period, before you may be eligible for benefits. The elimination 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 benefits.

Short term disability coverage plays a crucial role here, as it provides financial support during a temporary inability to work due to illness or injury, bridging the gap until you can access long-term disability coverage.

Read more: Short-Term vs. Long-Term Disability: What’s the Difference?

How long will your medical condition be covered?

Qualifying medical conditions are typically covered for the life of the policy as long as you remain disabled. Insurance benefits often end at age 65 or the maximum Social Security Retirement Age, whichever is later. However, there are some exceptions.

Limitations and exclusions

Most long-term disability policies contain “limitations to coverage” and “exclusions to coverage.”

  • Limitations to coverage: The condition is only covered for a certain period.
  • Exclusions to coverage: The condition is not covered at all.

For example, most policies contain a two-year coverage limitation for mental health-related disabilities. They also typically include a complete exclusion for conditions that are deemed pre-existing.

The legal fight over a limitation or exclusion can get very detailed. You should never immediately accept what your insurance company says is a limitation or an exclusion. Be sure to consult a long-term disability attorney to review your policy and verify this for you.

Our team at Roy Law Group knows disability insurance law inside and out. Reach out to us anytime to help understand your policy’s fine print.

Read more: How Long Does Long-Term Disability Last?

What can cause a long-term disability claim denial?

There are many reasons why a long-term disability claim can be denied. Common reasons for claim denial include insufficient evidence, ineligibility, missing a deadline, and mistakes on the claim form. Your insurance claim may also be denied at anytime if the company suspects your condition has improved.

It’s important to carefully review your denial letter to understand why your disability claim has been denied. Consult an experienced long-term disability lawyer for guidance on the best actions to take.

Get help with securing your benefits

Filing a long-term disability claim can be a confusing and stressful process. Many potential pitfalls can lead to your insurance company denying your claim. It is not the time to gamble on losing the continued care you need.

You are not alone. Our compassionate and caring team of long-term disability attorneys is here to help you win and heal.

Contact Roy Law Group today for help with navigating this complicated process.