Long-Term Disability Insurance Benefits
What is Long-Term Disability insurance?
Long-term disability (LTD) insurance replaces all or a percentage of your income if you cannot work due to a covered disability. You may have purchased individual LTD insurance through an agent or directly from the insurance company, or you might receive group disability insurance coverage through your employer. Some people have both individual and group LTD insurance coverage. In addition, some retirement or pension plans provide an LTD benefit.
Your policy will have specific requirements that you must meet in order to receive benefits, so it is important that you read your policy carefully to know the rules that apply to you. Among other things, you must meet your policy’s definition of disability. If you are eligible, LTD benefits from individual coverage usually start 60 – 180 days after the date of disability. LTD benefits from group coverage usually begin 180 days after the date of disability.
If you would like an overview of some different types of disability insurance benefits that might be available to you, click here to read about other types of disability insurance benefits.
Do I have LTD insurance coverage?
If you have been diagnosed with Parkinson’s disease (PD), you should determine whether you have LTD insurance coverage. It is a good idea to involve someone you trust – a family member, close friend, or your LTD attorney. For some, Parkinson’s disease can impair cognitive function and impact focus, memory, planning and organization. Even if the outward effects are subtle, cognitive impairment could cause you to make a mistake that could result in a benefit denial.
You may have purchased LTD coverage, or earned it as an employment benefit from work, or both. Here are some tips that you might consider using to determine whether you have LTD coverage.
Individual coverage: If you purchased an individual disability policy through an agent or directly from the insurance company, you probably paid premiums for coverage on an ongoing basis – monthly, quarterly, or annually. Review your financial records and checking accounts for evidence of these payments. If you find payments to an LTD insurance company, you might request a copy of your policy from the insurance company. If you have an insurance agent, you can also ask your agent to help you get a copy of your policy.
Group coverage through your employer: If you are not sure if you have LTD insurance through your employer, look at your pay stub. If you paid some or all of the monthly premium, that may be reported on your pay stub. If you are comfortable doing so, you might speak with human resources or your supervisor about disability and other benefits that are available to you.
If you earned your disability insurance coverage as an employment benefit, or purchased it through your employer, you can ask your human resource contact or supervisor for a copy of the Summary Plan Description (SPD) for each benefit plan and pension plan, in which you participate. Some employers allow you to access these documents online. The SPD should contain basic information about your coverage. However, there can be other documents that superseded the SPD if there is a discrepancy. Also, your coverage may be governed by more than one document. You can request a complete copy of your plan governing documents in writing from the plan administrator, which is usually the employer. See United States Code 29 U.S.C. §1024(b)(4).
Here is sample language for your request:
“I request all documents governing my coverage under all group plans sponsored by {***INSERT EMPLOYER NAME***} including, but not limited to, {***INSERT BENEFIT TYPE e.g. short-term disability, long-term disability, life, health, long-term care insurance, and pension***}. This request includes, but is not limited to, all documents to which I am entitled under ERISA 29 U.S.C. §1024(b)(4), such as the latest updated summary plan description, latest annual report, any terminal report, the bargaining agreement, trust agreement, contract, or other instruments under which the plan is established or operated.”
Am I eligible for LTD benefits?
To be eligible for LTD benefits, you need to have LTD insurance coverage and meet the plan or policy’s definition of disability, which usually requires that you are unable to perform the duties of your own occupation or another occupation due to sickness or injury. There can be other important requirements, and each LTD policy and claim is different, so you will need to read your policy carefully.
One of the most important elements of your policy is the definition of disability. Under most LTD policies, you do not need to be totally incapacitated to receive benefits. There are two main types of definitions of disability – “Own Occupation” and “Any Occupation”. These definitions can vary greatly depending on how your policy is written. Here are the general concepts:
Own Occupation – If you are covered under an Own Occupation definition of disability, you may qualify for benefits if you are unable to perform the material duties of the job that you were performing at the time your disability began. Most insurers view your job as it is performed in the national economy, not for your employer.
Any Occupation – If you are covered under an Any Occupation definition of disability, you may qualify for benefits if you are disabled from working in any job, reliably, full-time. Some policies will pay you benefits if you can’t work in a job given your age, training, education, or experience. Others may pay benefits if you can’t work in a job, in which you would earn at least a percentage of your pre-disability earnings.
Commonly, LTD benefits will be governed by an Own Occupation definition of disabled for the first 12 to 24 months of your claim. Then, the remainder of the claim will be governed by an Any Occupation definition of disability.
Some LTD policies will pay you benefits if you are partially disabled. Like the terms “Own Occupation” and “Any Occupation”, the term “Partial Disability” can be defined differently so read your policy or plan documents carefully. For example, it could mean that you are earning work income from performing some but not all of the material duties of your own occupation or any occupation, or that you can perform all of the material duties, but not on a full-time basis. It is important to read your policy to determine how Partial Disability is defined.
Regardless of your policy’s definition of disability, your Parkinson’s disease diagnosis is probably, alone, not enough to win your claim. Many with Parkinson’s disease are able to work for a long time after receiving a diagnosis. Thus, if you are filing a claim, it is important that you provide medical evidence that your Parkinson’s disease symptoms are of a level of severity that prevent you from working. Even if you are still working and not ready to make a claim, be sure that your doctors are documenting your symptoms in your medical records. If your symptoms progress to the point of disability, having the symptom progression documented in the medical records can help you prove your claim and explain what changed over time to render you disabled.
How do I apply for LTD benefits?
Organize your thoughts: When you are ready to apply for LTD benefits, take a moment to think about your symptoms and how they impact your ability to work in any job reliably and consistently. It can help to write yourself a note about this so that this is in the front of your mind throughout the process. Begin by asking yourself the following:
- What are the important tasks and duties that you must perform to do your own occupation?
- What symptoms do you experience? Here are some common Parkinson’s disease symptoms:
- tremor
- bradykinesia (slowing or loss of ability to voluntarily initiate movement)
- rigidity (stiffness in a limb or other body part)
- postural instability (difficult maintaining balance and coordination)
- trouble walking
- dystonia (painful and prolonged muscle contractions)
- orthostatic hypotension (fluctuating low blood pressure)
- cognitive impairment (impaired memory, problem solving, planning and organizing, multitasking, paying attention or thought processing)
- mood disorders such as depression and anxiety
- sleep disorders such as insomnia, daytime sleepiness, REM sleep behavior disorder, restless leg syndrome, and obstructive sleep apnea
- digestive problems
- How do your symptoms interfere with your work?
- Do any of your symptoms prevent you from reliably and consistently working in any job?
Submit notice of claim: Your application process will begin when you provide notice of your claim to the insurance company. Providing notice of claim typically involves informing the insurance company that you are disabled, providing the date that your disability began, and stating what caused the disability. Depending on the terms of your LTD policy, you may have to provide notice of claim in writing. Many LTD policies require notice of claim within a certain time period running from the date of your disability. If there is a deadline, it should be in your policy.
Collect and submit evidence of your disability: Start gathering evidence for your claim as soon as possible. It is your responsibility to prove that you are disabled. The insurance company will not do this for you. Read your policy to determine what evidence is needed to prove your claim. The insurer may request your medical records from your care providers. However, do not rely on the insurance company to prove your claim for you. Consider collecting the medical records that you need to prove your disability and then submit them to the insurance company in support of your claim.
There are more sources of evidence than just medical records. For example, you might ask your doctor to write a report about how your symptoms impair you. You also might gather test result reports, photos, a symptom log that you or a loved one prepared, a personal statement that you prepare, or witness statements (from family, friends or co-workers). If you are having trouble remembering, concentrating or keeping organized, your doctor may send you for a neuropsychological examination to assess and quantify how your Parkinson’s disease impacts your brain function. Your doctor may also send you for a functional capacity examination to measure your physical limitations.
Do not wait for the insurance company to ask for information to begin collecting evidence. Start gathering your evidence as soon as possible. The evidence that you collect might help you complete the claim forms discussed below. When you submit information to the insurer, do it in writing, save a copy of what you sent along with proof that you sent it such as certified mail receipt, Federal Express confirmation, fax confirmation, or secure email receipt.
Complete and submit claim forms: After you provide notice of claim, the insurance company may provide you with claim forms to complete. You, your doctor, and your employer will probably have to complete claim forms. There are different types of forms, and they can be called different names. Typically, the forms that your insurer will require include an individual statement that you complete, an attending physician statement that your doctor completes, and a work history form that you and/or your employer must complete. You will likely also have to sign a medical authorization. Here are some examples of common LTD claim forms (the names of these forms can vary from one insurer to the next, but the same concepts should apply):
- Individual Statement: In the individual statement, you will typically be asked to provide basic information about yourself such as your contact information, date of birth, work history and medical history. You may have to report your date last worked or your date of disability. You may be asked to report what work activities or non-work activities you could do before, but that you cannot do now because of your disability.
- Attending Physician Statement: The attending physician statement (APS) is the form that your doctor must complete. In the APS, your doctor may be asked to report information such as your diagnosis, medications, examination findings, test results, and your doctor’s opinion as to your level of impairment.
- Job Description / Work History Statement: The insurer may ask you to complete a form in which you describe the work that you did before you became disabled, commonly called your “own occupation”, “regular occupation” or “regular job”. When doing this, it is important that you report both the physical and cognitive demands of your job.
- Medical Authorization: The insurance company will likely require you to sign authorizations allowing your doctors to provide information about you and your health to the insurance company. The insurer might use the authorization to collect medical records, ask your doctor to complete forms, or speak on the phone with its claim consultants.
Wait for the insurance company investigation: You should assume that the insurance company is investigating your claim as soon as it knows that you intend to make a claim. Every communication that you have with the insurer can be used for or against you by the insurance company. Here are some claim investigation tools that are commonly used by insurers:
- File Reviews: File reviews are one of the most common tools used by insurers to investigate LTD claims. The file reviewer is an employee or contractor of the insurance company, often a nurse or a doctor, who reviews your claim forms and medical records. The file reviewer then issues an opinion. The opinion may outline the reviewer’s opinion about what restrictions and limitations are supported by the records. Other times, the reviewer responds to specific questions posed by the claim handler. Sometimes, the file reviewer will write to your treatment providers to ask them questions. The file reviewer might also telephone your doctor to discuss your claim. These calls are commonly referred to as peer-to-peer phone calls.
- Independent Medical Examinations (IME): The insurer may require you to be examined by a doctor of its choosing. Be aware that these doctors are paid by the insurer (or a third-party company hired by the insurer).
- Surveillance: One of the more unsettling things LTD claimants learn is that the insurer might be watching them and recording their activity. Video surveillance is not conducted on every claim. However, insurers sometimes hire investigators to monitor and record claimant activity. This surveillance will be reviewed by the claim handler and file reviewers who decide your claim. Insurers might show the surveillance video to your doctors.
- Internet and Social Media Investigation: You can expect that the insurer will plug your name into search engines and try to find you on social media platforms like Facebook. If you are not comfortable with this, change your Facebook privacy settings to restrict unwanted public access to your content.
- Financial Investigation: Depending on your circumstances and the terms of your policy, the insurer may ask for information about your earnings. For example, if you are partially disabled and are still working and earning on a limited basis, the insurer may closely monitor your earnings to calculate your partial disability benefit. You also may need to distinguish between income earned from working, and investment or business ownership income that you might continue to receive even though you are not able to work.
Receive a claim decision: The insurance company should issue a claim decision after it completes its investigation. Read your LTD policy to learn what if any deadline the insurance company has to make a decision. Sometimes an insurance company will delay making a decision if it feels it needs more information. Hopefully, if you meet your LTD policy’s conditions for coverage, your claim will be approved.
You might receive a call approving your claim, followed by a letter. Some claimants just receive a letter. Payment should follow shortly after claim approval.
If you are denied, take it seriously, but don’t despair. Your policy should provide you with a right to appeal the decision. For many, this is a time when you should consult a lawyer. The appeal might be your last chance to submit evidence in support of a claim. You should not delay in pursuing your appeal. There is often much to be done and you probably have a limited time to file your appeal. Missing your appeal deadline could mean permanently losing your rights to your LTD benefits and even losing your rights to file claims in court. The denial letter and your policy should contain deadlines and rules for pursuing your appeal.
What are some common coverage limitations that could apply to my Long Term Disability claim?
Most disability insurance will exclude or limit coverage for certain conditions. The applicability and impact of a limitation on your claim requires careful analysis of the policy language, facts of your case, and the applicable law. Still, the following information may help you identify whether you have a potential coverage limitation issue.
Pre-existing condition limitation: A pre-existing condition limitation can exclude coverage for disabilities caused by conditions that you had, or for which you received treatment, before you were covered under the policy.
Mental illness limitation: Commonly, benefits for mental illness such as depression or anxiety are limited to 12 or 24 months. This can be of particular concern for those with Parkinson’s disease because there can be significant emotional symptoms caused by the disease and side effects of medications. It is important that you identify and document the physical impairments from Parkinson’s disease that impact your ability to work.
Appropriate care and treatment: Most policies will not pay benefits unless you are receiving appropriate care and treatment for your Parkinson’s disease. That does not mean that you must engage in all possible therapies. However, you should be under the care of a treatment team, including a neurologist. You and your care providers should agree on a course of therapy and stick to it unless it is appropriate to modify it. Failure to do so can result in a benefit denial.
nbsp;
APDA makes this information available solely for the purpose of general education. It is not intended as specific advice for your specific circumstance or as legal, insurance or medical advice. APDA encourages those who find this information useful to contact a legal advisor for answers to specific questions and assistance. The following information was graciously provided by the disability law firm of Chisholm Chisholm & Kilpatrick LTD, with support from Douglas L. DuMond of Simian Advisors LLC. APDA does not endorse any disability law firm or have a formal affiliation with CCK or Simian Advisors LLC.