Wondering what medical conditions qualify for long-term disability benefits? Generally speaking, long-term disability insurance covers a wide range of medical conditions. Although no two insurance policies are exactly alike, some general similarities in coverage exist.
If you have a medical condition that prevents you from working, you may be eligible for long-term disability benefits. Here are some common qualifying conditions and what you need to know about getting the benefits you deserve.
Common medical conditions that qualify for long-term disability
Long-term disability insurance covers restrictions and limitations caused by injuries or illness. These benefits generally start after your short-term disability benefits are exhausted.
Here are some of the most common medical conditions that qualify for long-term disability:
- Mental health-related disorders, e.g., generalized anxiety, major depression, bipolar, and post-traumatic stress disorder (PTSD)
- Musculoskeletal disorders, e.g., carpal 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
How is eligibility for benefits determined?
How does a disability insurance company determine if your medical condition qualifies for long-term disability benefits? Determining eligibility for benefits is where things get complicated.
Proof of disability
First, your disability insurance company will require that you provide evidence of your disability.
In your insurance policy, this process is outlined under a section often titled “Proof of Claim.” You must notify your insurance company and submit all required claim forms and documentation to file an insurance claim. This may include providing medical records.
The claims process can be pretty 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 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 job. This is often based on how that job is defined in the national economy, not by 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 prove that you’re unable to perform the duties of any job or that you’re unable to make at least a certain percentage of your income before becoming disabled.
As you can see, under most long-term disability policies, it becomes much more challenging to qualify for benefits after 24 months.
How long will your medical condition be covered?
Qualifying medical conditions are typically covered for the policy’s life as long as you remain disabled. 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 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.
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 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 regularly.
- 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 documents it has requested and received.
- Missed deadlines: Pay careful attention to filing deadlines. Adhering to deadlines becomes most important when filing an appeal.
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.