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Social security denial - a journal of assistance

3 Important Questions To Find Answers To Before Filing For Long Term Disability

16 January 2017

Alexis Garcia

If you are currently on short term disability and need to file a long term disability claim, there are a few important questions you need answers to first. Long term disability is governed by the Employee Retirement Income Security Act of 1974, which means there are minimum standards the insurance company has to abide by. However, each company is able to set their own policies as long as they remain within the standards. Here's what you need to know about ERISA disability claims. 

What is the time limit you have to follow? 

Typically, long term disability policies have strict time limits for the initial filing of a claim and each subsequent appeal, if any are necessary. Therefore, the first thing to understand is what the statute of limitations are. This should be written in easy to understand terminology directly in the insurance policy, which you can get a copy of through your human resources department or your direct supervisor. 

It's important to note that, depending on your illness and the availability of specialists, it can sometimes take longer to get the appropriate medical care and treatment for your specific illness than the time that is allotted in a long term disability plan. For example, perhaps you were given a referral to a specialist and their first available appointment for a new patient was 4-6 months away, yet you need to file a claim within 90 days according to your insurance company's specific policy. By knowing what time constraints you are under, you would know whether or not to reschedule that appointment with a different specialist. 

Can your medical condition be considered a pre-existing condition? 

One common reason insurance companies deny long term disability coverage is due to pre-existing conditions. Many policies will not provide long term disability payments to those with medical complaints of pre-existing conditions. However, this may also have a time limit. Sometimes, a pre-existing condition may be considered if the policy accepts them up to a specific time frame prior to the beginning of the policy. 

It's important to delve into the insurance policy to find the specific wording that is used to describe pre-existing conditions. If the wording used in the policy describes a pre-existing condition as one "for which" you were being treated yet you were not diagnosed with any specific medical condition even though you were seeking medical care for your ailment(s), you may still qualify. Generally, you cannot be treated "for" a medical condition unless you have a diagnosis "of" a medical condition. 

Does the policy cover "any" or "own" occupation? 

It's important to know whether or not the insurance policy covers your own occupation (the occupation you held when you became ill or injured) or any occupation. If the policy falls into the "own occupation" category, you can qualify for long term disability if you are unable to perform the duties and tasks of your occupation. If the policy covers "any occupation" you can qualify if you are unable to be engaged in any gainful occupation, regardless of whether or not it has to do with your current occupation. For example, if you are employed as a nurse but still able to work as a cashier, an "any occupation" policy will likely be denied. 

If your policy falls into the any occupation category, you'll need to be sure to have a thorough functional capacity evaluation (FCE) done by your primary care physician. This test is used to determine details such as how long you can sit and stand and how much weight you can lift without aggravating your illness or injury. It's also a good idea to include nonexertional limitations in the test, which would show things such as your ability to concentrate and focus. 

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