Long-term disability insurance generally covers a wide variety of medical conditions. Although no two insurance policies are exactly alike, some general similarities do exist.
Here are some of the most common qualifying medical conditions and what you need to know about getting long-term disability benefits.
Common qualifying medical conditions
Long-term disability covers restrictions and limitations caused by injuries or illness. These benefits generally start after your short-term disability benefits are exhausted.
Some of the most common medical conditions that qualify for long-term disability are:
- Mental health-related disorders, e.g., generalized anxiety, major depressive, bipolar, and post traumatic stress disorder (PTSD)
- Musculoskeletal disorders, e.g., carpel tunnel syndrome, osteoarthritis, rheumatoid arthritis (RA), fibromyalgia, degenerative disc disease, failed back syndrome, and injuries to the thoracic or cervical Spine
- Traumatic brain injury
- Chronic obstructive pulmonary disease (COPD)
- Crohn’s disease
- Heart disease
- Multiple sclerosis (MS)
- Parkinson’s disease
This is just a snapshot of potential qualifying conditions, which will vary from policy to policy.
How is coverage determined?
How does a disability insurance company determine if your medical condition qualifies for long-term disability coverage? This is where things get complicated.
Proof of disability
First, your disability insurance company will require that you provide proof of your disability.
In your insurance policy, this process is outlined under a section often titled “Proof of Claim.” You will have to send notice to your insurance company, and then complete and file all claim forms and any other information requested.
The claims process can be quite involved. It may take anywhere from a couple of weeks to a few months to complete, depending on the severity of your injury or illness.
Definition of disability
Your insurance policy will outline its own specific definition of a long-term disability. This definition is generally based on whether you can work in your “own occupation” or “any occupation.”
- Own occupation: You are disabled if you’re medically unable to carry out the duties of your own particular job. This is often based on how that job is defined in the national economy, not your specific employer. This coverage typically only lasts 24 months under most policies.
- Any occupation: After the initial 24 months, your disability is defined more narrowly. In most cases, you have to either prove that you’re unable to perform the duties of any job whatsoever, or that you’re unable to make at least a certain percentage of your income prior to becoming disabled.
As you can see, under most long-term disability policies, it becomes much more difficult to qualify for benefits after 24 months.
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 under the policy. It’s common for insurance policies to terminate at age 65 or your maximum Social Security Retirement Age (SSRA), whichever is longer. 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 period of time.
- Exclusions to coverage: The condition is not covered at all.
For example, most policies contain a two-year limitation of coverage for mental health-related disabilities. They also typically include a complete exclusion for conditions that are deemed pre-existing.
The legal fight over what is 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 first consult an 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 for help with understanding the fine print of your policy.
What can cause a long-term disability claim denial?
Unfortunately, disability insurance companies will look to “punch holes” in your claim. It’s not unusual for benefits to be denied based on a very minor error in your file or a missing document. Delays and claim rejection can quite literally change your future well-being.
Some common mistakes that lead to claim denials include:
- Failure to go for regular medical treatment: Your insurance company will expect you to visit your primary care physician and appropriate specialists on a regular basis.
- Missing medical records or other required documentation: Be proactive. Don’t assume your disability insurance company is diligently collecting your records. Ask for a list of records it has requested and received.
- Missed deadlines: Pay careful attention to filing deadlines. This becomes most important when filing an appeal if your claim is denied.
Get help with securing your benefits
Filing a disability claim can be a confusing and stressful process. There are many potential pitfalls that can lead to your claim being denied. 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 are here to help you win and heal.
Contact Roy Law Group today for help with navigating this complicated process.