Who is Eligible for Long Term Disability?

Disability Wiki.

Having insurance of any sort is an interesting proposition. Whether required by law or optional or whether it's provided by one’s employer or purchased privately, most people acquire various policies protecting different interests all with the hope of never having to be in the position of needing the benefits the policy coverage provides. However, as obvious as it may seem to the person making a claim for long term disability benefits that they are disabled and cannot work, it is the insurance carrier who makes that decision.  As our NY disability attorneys can attest, many claimants are surprised to learn that they have had their claim denied.

Initial Considerations

Like any type of insurance, there are limitations, exclusions and basic eligibility requirements. Most employer-provided insurance plans require an employee to work for a certain period of time before they are covered. Additionally, most long term disability policies require the covered employee to work full time, which typically is defined as at least 30 hours per week.

Elimination Period

Every long term disability policy has a waiting period, which is the amount of time between when a covered individual became disabled and the day the insurance carrier will begin to pay benefits. This so-called elimination period is typically three or six months. In policies that also include short term disability coverage, long term benefits begin after the short term benefits have been exhausted.

Some cases have a clear date when the claimant became disabled; an accident, for example, that caused some debilitating physical injury is a date certain.  In other instances, it is not so obvious.  An illness or disease can develop over a period of time and the full symptoms may not be observable for many months or longer. Of course, the claimant will suggest their disability began at the onset of the symptoms, but the insurance carrier may consider the issue differently.

Own Occupation/Any Occupation

Most long term policies have the terms “Own Occupation Period” and “Any Occupation Period” included.  During the Own Occupation Period, the individual must be unable to perform the material and substantial duties of their specific occupation due to their disability. The Any Occupation Period means the disabled person must be unable to perform the material and substantial duties of any occupation they are reasonably capable of doing in consideration of their training, education and experience.

Many policies are written so that the claimant must meet the Own Occupation Period standard for 24 months and thereafter receives benefits only if they meet the Any Occupation Period standard. Most often, Any Occupation standards do not have minimum income requirements; the claimant is evaluated on their ability to do any type of job.  Even though the person’s medical condition may not have changed at all, they may not fit the definition of “disabled” when evaluated under the Any Occupation criteria.

Pre-Existing Conditions

Under certain circumstances, even if a claimant meets the insurance carrier’s definition of disability, they will be denied benefits. One common reason is if the insurance company has reason to suspect that the claimant’s medical condition upon which they are basing their claim was in existence prior to the time when the policy took effect. Different provisions in a long-term disability policy will limit the coverage of a preexisting condition.

One such provision is what is called a “look back” period. This means the insurance company will closely examine the claimant’s medical record for a specific period of time before the policy became effective. Look back periods are typically between three and 12 months.

Work-Related Accidents or Illnesses

Generally speaking, workers’ compensation is the exclusive remedy for an employee who has been injured and cannot work due to an incident that occurred in the course of work.  Most long term disability insurance policies provide an offset for workers compensation benefits; the monthly long term disability benefit will be reduced by the amount of the monthly workers’ comp payment.

The Insurance Company’s Definition of Disabled

When a claimant files a claim for disability benefits, the insurance company will have one of their in-house doctors or nurses review the claimant’s complete medical records. No matter how long the claimant’s physicians have been treating the claimant or how well credentialed any of the doctors may be, the insurance company’s employee is very likely to disagree with the conclusion of the claimant’s medical representatives. Unlike Social Security Disability cases, the treating physician’s opinion is not given any deferential treatment.

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