When a person with a disability is completing his or her application for long term disability benefits, they may not realize the terms they must meet in order to receive disability benefits. While long term disability policies can vary greatly, there are some common provisions found within the policies. The below provisions are commonly found in long term disability policies, but please carefully review your policy to learn the specific requirements of receiving long term disability benefits.
Definition of Disability Every long term disability policy will include a definition of Disability or Total Disability. It is common for this definition to be broken into two parts. Often, the first part defines disability as an injury or illness that prevents the claimant from performing the duties of his or her own occupation. The second part pertains to the disability after a set time period, such as 24 months. This second part defines disability as the same injury or illness that prevents the claimant from performing the duties of any occupation.
It is also worth noting that there can be important terms within the definition of disability. For example, some definitions define “own occupation” as one that is performed in the national economy and can be found in the Dictionary of Occupational Titles. Another example is the definition of “injury” or “illness”, which may exclude conditions such as alcoholism or injuries from self-harm. The term “any occupation” may be defined as an occupation that the claimant’s experience and training reasonably allows. Because of the important terms within the definition of disability, you will want to carefully review the policy’s definition of each term, so that you fully understand the requirements within the definition of disability.
Elimination Period and Other Requirements Many definitions of disability include more requirements than those mentioned above. One of the most common additional requirements is that a claimant meets an elimination period. An elimination period is usually defined as a set amount of time (such as 180 days) that a claimant must prove to be disabled before becoming eligible for long term disability benefits. An elimination period is important in two ways: 1) a claimant must provide medical documentation showing that they were disabled during this time frame and 2) a claimant will not receive long term disability benefits until the elimination period is exhausted.
Because so many variations in the requirements of disability exist, it is crucial to examine the entire long term disability policy carefully. One common requirement in disability policies is that the insured’s disability prevents him from earning 60% or more of his previous earnings (this provision may also allow a person to work part-time, but still qualify for long term disability benefits). An insurance policy could require that a claimant maintains regular treatment with his physician. Other policies may even require that a disability be supported by objective evidence, such as blood tests, x-rays, or MRIs. Some policies may require that a person be approved for disability benefits by the Social Security Administration.
Limitations in the Policy There are some common limitations that appear in long term disability policies. One is the exclusion of a pre-existing condition. Generally, this limitation states that if a claimant files a long term disability claim within a certain time after becoming insured (such as 12 months), then the insurance company can review the claimant’s medical history to learn whether this condition is pre-existing. Any prior treatment that a claimant has had for a pre-existing condition could affect their eligibility to receive long term disability benefits.
Another common provision is a limitation for mental health disorders. Usually, limitations for mental health disorders do not come into play until a claimant has been receiving disability benefits for 12 months or 24 months. If a claimant’s disability is caused solely from a mental health condition, like depression, their disability benefits could be limited to the defined time period in the disability policy. It is worthwhile to carefully review the definition of “mental health conditions” because some disorders, like organic brain disease or dementia, may be omitted from the definition of mental health condition.
Appeal requirements Finally, a claimant may not be eligible for long term disability benefits if her claim has been denied and she failed to follow the policy’s appeal procedures. Almost every disability policy requires that a denied claimant file an appeal within a certain deadline, such as 90 or 180 days from the notification of denial. If the long term disability policy is governed by the Employee Retirement Income Security Act (ERISA), then the appeal procedures must conform to ERISA requirements.
Because a long term disability claimant’s appeal can have a significant impact on whether or not they receive disability benefits, contact the O’Ryan Law Firm immediately if your disability benefits have been denied. The O’Ryan Law Firm can review your disability claim and provide a free consultation about your disability benefits.