How to Win Your Long Term Disability Claim | The Basics

Disability Wiki.

You’ve suffered an injury or experienced the progression or exacerbation of a sickness or illness that makes it difficult, if not impossible, for you to complete your job duties. You have Long Term Disability coverage through an individual policy that you purchased yourself, a group policy issued by an insurer to your employer, or both.  Now you need to apply for benefits.

What do you do first?

At Riemer Hess, we know that it can be a daunting task to complete the necessary claim forms and apply for LTD benefits – particularly when you are suffering from the debilitating effects of a debilitating injury or illness.  We will take the burden off of your shoulders by preparing your LTD application, and more importantly, by helping you to avoid the “minefields” that hurt so many claimants.

How And When Should I File an LTD Claim After My Disability Begins?

You should begin the application process immediately after your disability begins. Initiating a claim for Long Term Disability benefits is a two-step process. First, you must submit a Notice of Claim – typically within 20 or 30 days from the date your disability begins (the “Date of Disability”).  The Notice of Claim is a short letter alerting the insurance company that a claim for LTD benefits will be submitted.  It generally must include your name, date of birth, policy number and your Date of Disability.

Second, once the Notice of Claim is received, the insurer will provide you with forms that must be completed before your LTD claim can be evaluated. These forms are called Proof of Claim (or Loss), and usually must be completed and submitted to the insurance carrier within a specified number of days (typically 90-days) after the end of the Elimination Period (the waiting period from the Date of Disability to the first date in which you are entitled to benefits). The Elimination Period is usually 90 or 180 days.

What Must Be Included As Part of My Proof of Claim?

Proof of Claim forms generally consist of three parts: (1) the Employer Statement; (2) the Claimant Statement; and (3) the Attending Physician Statement. The Statements must be made on printed forms supplied by the insurance company. In completing these forms, you must prove you have a sickness or injury that results in a decreased residual functional capacity, which prevents you from performing the duties of your job.  A disability attorney will say that if you cannot prove your sickness or injury, you have a very small chance of completing the process successfully.

Employer Statement

The Employer Statement is a form completed by your supervisor or a benefits/human resources specialist, and provides general information regarding your job title; job duties; salary and other compensation; eligibility for LTD benefits, the date you started and stopped working, etc. With regard to your job duties, your employer will need to submit a copy of your job description. In addition, the insurer may require that your employer complete a Physical Demands Analysis, which addresses the physical and cognitive demands of your job including your work schedule; machines and tools used; educational/training requirements of your job; hours standing, walking and sitting at one time and total during the workday; other physical demands such as climbing, lifting, carrying, stooping, kneeling, handling, grasping, fingering, etc.; and talking, vision, hearing and reading requirements.  Depending on your private disability insurance company, the rules and requirements may vary.

Claimant Statement

The Claimant Statement is your chance to explain to the private disability insurance company why you are disabled.  Claimant statements will begin by asking general questions such as your name and contact information, your employer’s name and contact information, your occupational title and job duties, etc.  It then will ask specific questions about the nature of your disability, the effects of your disability (e.g., your restrictions and limitations), and why you cannot perform your job duties. The claimant statement will seek the contact information for your treating physicians and information about any hospitalizations related to your disability.  It typically concludes by asking about other income benefits, which may offset your LTD benefits (e.g., whether you have or anticipate receiving state mandated short term disability (“STD”) benefits, supplemental STD benefits, social security disability benefits, workers’ compensation benefits, pension benefits, etc.).  Our disability lawyers in New York  will be able to help you ensure that this claimant statement is as detailed and accurate as possible.

Attending Physician Statement

The Attending Physician Statement (the “APS”) is the most important part of your application. The form will ask your doctor to list your diagnoses, subjective symptoms, objective findings, treatment plan, etc.  Next, the APS will ask your doctor to list the restrictions and limitations caused by your disabling medical conditions.  Our disability lawyers in New York  will work with you to make sure that all required elements of these forms are filled out correctly. The form may ask the doctor for a narrative description of your limitations or it may ask him/her to answer more specific questions regarding how long you can sit, stand, and walk; how much weight you can lift/carry and push/pull; and how often you can stoop, bend, crawl, reach, use your hands/fingers for grasping, handling and fine manipulations; etc.  Your treating doctor must document restrictions and limitations that will prevent you from performing the duties of your own or any occupation (depending on the LTD Policy’s definition of disability).

How Long Does An Insurer Have To Make a Decision On My Claim?

Once the Proof of Claim forms are submitted, the private disability insurance carrier will begin its review of your LTD claim.  Insurers may request an in-person or telephonic interview to discuss the specifics of your claim. They also may decide to send you for an Independent Medical Examination or a Functional Capacity Evaluation in order to better ascertain the limitations caused by your medical conditions.  Once the review is completed, the disability insurance company will render a decision.  According to ERISA, an insurance carrier has 45-days to make a decision on an initial claim.  However, they may request two extensions of 30-days each. Therefore, the disability insurance company has up to 105 days to decide the initial claim.

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