Long-term disability (LTD) insurance can provide financial help if you are unable to work for an extended period of time due to a qualifying medical condition. To qualify for benefits, your medical condition must meet the definition of long-term disability set by your insurance provider in your policy.
In this article, we’ll cover what medical conditions typically qualify for long-term disability and what you need to know about getting the benefits you deserve.
What we’ll cover:
- What medical conditions qualify for long-term disability?
- How is eligibility for long-term disability determined?
- How long will your medical condition be covered?
- What can cause a long-term disability claim denial?
What medical conditions qualify for long-term disability?
Medical conditions that qualify for long-term disability benefits may include physical or mental illnesses, serious injuries, or any chronic conditions that prevent you from working for an extended period of time.
These benefits generally kick in after your short-term disability benefits are exhausted, and the type of policy and insurance provider will determine the exact conditions that qualify.
Here are some of the most common medical conditions that qualify for long-term disability:
- Chronic obstructive pulmonary disease (COPD)
- Chronic pain
- Crohn’s disease
- Heart disease
- Long COVID
- Mental health-related disorders (anxiety, depression, etc.)
- Multiple sclerosis (MS)
- Musculoskeletal disorders
- Parkinson’s disease
- Traumatic brain injury
Some policies may also provide benefits for certain disabilities caused by accidents or occupational injuries. It’s important to check with your provider to determine what conditions are covered under your specific policy.
How is eligibility for long-term disability determined?
Eligibility for long-term disability is typically determined by a combination of factors, including age, medical history, current physical and mental health status, and ability to perform essential job duties. You must provide proof of your disability to your insurance company to show that it prevents you from working and meets the policy’s definition of disability.
Proof of disability
First, your disability insurance company will require that you provide medical records, including any diagnostic tests and other medical evidence that may be relevant to your disability claim.
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, including 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 company will also evaluate your ability to continue working in the same role or in a different capacity, based on your work history and job duties. Your policy will outline its specific definition of a long-term disability, which 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 must prove that you’re unable to perform the duties of any job or make at least a certain percentage of your pre-disability income.
As you can see, under most long-term disability policies, it becomes much more challenging to qualify for benefits after 24 months.
Read more: How Long Does Long-Term Disability Last?
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. It’s common for insurance policies to terminate benefits at age 65 or your maximum Social Security Retirement Age, 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?
There are many reasons why a long-term disability claim can be denied. These include failing to provide sufficient evidence to support the claim, not meeting the eligibility requirements or definition of a disability, not filing a claim on time, or making a mistake on a claim form.
Additionally, your insurance company may deny your claim if they believe that your disability has improved or is not as severe as claimed, or that you are engaging in activities that would not be possible if you were truly disabled.
It’s important to carefully review all the information provided with the denial to understand why your disability claim has been denied and seek the help of an experienced long-term disability lawyer’s help to determine the best course of action.
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.