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 financial help if you can’t work because of a serious medical issue. But proving that your medical condition is a disability can make a stressful situation even harder.
In this article, we’ll outline some medical conditions that typically qualify for long-term disability benefits. We’ll also cover some of the typical eligibility requirements and potential challenges you may encounter.
We strongly recommend that you 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:
- General requirements for qualifying for LTD benefits
- Common medical conditions that qualify for disability
- How long will your medical condition be covered?
- What can cause a long-term disability claim denial?
- Get help with securing your benefits
General requirements for qualifying for LTD benefits
Before we look at specific medical conditions, let’s review the general requirements for long-term disability benefits.
Policy terms
Insurance policies can vary widely, offering different levels of coverage, terms, and eligibility requirements. Understanding the terms and conditions of your insurance policy is the first step to getting the support you need.
A key factor to consider is that your medical condition must meet your insurance policy’s definition of disability. Your policy will typically define disability based on your ability to work in your ‘own occupation’ or ‘any occupation.’
Review your policy carefully to understand the coverage your plan offers. This will also help you anticipate any challenges in qualifying for benefits.
Proof of disability
You must provide your insurance company with detailed 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. 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 it will vary depending on the specific policy. You must remain continuously disabled during the elimination period to be eligible for benefits.
At this time, you can explore your options with short-term disability or Social Security Disability Insurance (SSDI). These benefits can help to bridge the financial gap while you are applying for long-term disability benefits. Also, if you qualify for SSDI benefits, this could even boost your chances of winning your LTD benefits.
Read more: Short-Term vs. Long-Term Disability: What’s the Difference?
Common medical conditions that qualify for disability
Qualifying medical conditions for long-term disability benefits can include many physical or mental illnesses or serious injuries. Generally speaking, a medical condition must be serious enough to prevent you from working for an extended period. Additionally, you must provide sufficient medical evidence to prove it.
Below are the main categories of medical conditions that often meet long-term disability qualifications.
Back pain and musculoskeletal disorders
According to the Council for Disability Income Awareness, musculoskeletal disorders are the most common reason for LTD claims. They affect nearly 30% of all long-term disability claimants.
- Arthritis
- Back pain or injury
- Degenerative disc disease
- Fibromyalgia
- Joint disorders
- Herniated disc
Learn how our team won a disability claim for a client with chronic back pain: Paulson v. Principal Life Insurance.
Cancer
Cancer is the second-most common cause of long-term disability. “Early-onset” cancers are on the rise among adults between the ages of 18 and 49.
If you’re dealing with cancer, you may frequently require treatments such as chemotherapy and radiation. These treatments can have debilitating side effects that impact your ability to work.
Cardiovascular disease
Heart-related conditions can severely restrict your ability to perform physical and sometimes even sedentary work.
Some common cardiovascular disorders include:
- Atrial fibrillation
- Congestive heart failure
- Coronary heart disease
- Heart attack
- Hypertension (high blood pressure)
- Stroke
- Transient Ischemic Attacks (TIAs)
Chronic pain and fatigue
Chronic pain and fatigue can significantly impact your day-to-day life. However, because these symptoms are subjective, it can be difficult to prove how debilitating they can be. Conditions like chronic fatigue syndrome or fibromyalgia can be especially difficult to measure.
You must obtain a diagnosis from a qualified healthcare provider to identify the underlying cause of your symptoms. Keep detailed medical records and a symptom journal to document your functional limitations. Letters of support from family members, friends, and medical specialists can also be helpful.
Chronic respiratory conditions
Respiratory disorders can severely limit your physical capacity and stamina. Even routine activities can become exhausting, making it difficult to maintain employment.
These are some common respiratory conditions that may qualify for LTD benefits:
- Asthma
- Chronic Obstructive Pulmonary Disease (COPD)
- Cystic fibrosis
- Long COVID
- Pulmonary Fibrosis
Digestive system disorders
Many different digestive system disorders may be eligible for long-term disability if they are severe enough. Your issues must be chronic, well-documented, and supported by a medical specialist.
According to a recent survey by the American Gastroenterological Association, nearly 40% of Americans are affected by gastrointestinal (GI) issues.
Some of the most common digestive system disorders that may qualify are:
- Celiac disease
- Chronic liver disease
- Crohn’s disease
- Inflammatory Bowel Disease
- Irritable Bowel Syndrome (IBS)
- Ulcerative colitis
Read how our team secured LTD benefits for a client with a severe digestive disorder: Ray v Reliance Standard.
Immune system disorders
Long-term disability plans may cover immune system disorders, as they can often result in severe physical limitations.
Potentially qualifying medical conditions may include:
- Hepatitis B
- Hepatitis C
- HIV/AIDS
- Meningitis
- Lupus
- Vasculitis
Mental health disorders
A wide range of mental health conditions may qualify for long-term disability, depending on your policy. Mental health issues can affect focus and lead to exhaustion, hindering your ability to fulfill your work responsibilities.
Some common mental disorders include:
- Anxiety disorders
- Bipolar disorder
- Depression
- Panic attacks
- Post-Traumatic Stress Disorder (PTSD)
- Schizophrenia
Proving the effects of mental health conditions on your ability to work can be difficult, but not impossible. Be sure to maintain consistent medical treatment and keep detailed records to document your condition. Keep in mind that insurance providers typically limit benefits for mental health claims to a maximum of 24 months.
You can also pursue short-term disability benefits for mental health issues that arise suddenly and unexpectedly. Read more here: How to Get Short-Term Disability for Mental Health.
Neurological disorders or traumatic brain injury
Neurological disorders encompass a broad range of conditions that affect the brain, spinal cord, and nerves throughout the body. These disorders can have a significant impact on your ability to work, causing balance issues, cognitive impairment, and fatigue.
Some neurological disorders that may qualify for long-term disability include:
- Alzheimer’s disease
- Amyotrophic Lateral Sclerosis (ALS, or Lou Gehrig’s Disease)
- Epilepsy
- Multiple Sclerosis (MS)
- Parkinson’s disease
- Traumatic Brain Injury (TBI)
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, as mentioned, most policies contain a two-year coverage limitation for mental health-related disabilities. They also typically include a complete exclusion for pre-existing conditions.
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 any time 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.
This article was originally published on April 15, 2020 but has since been updated for accuracy and relevancy.