MAKING A SUCCESSFUL CLAIM FOR LONG-TERM DISABILITY
by
Mark E. Hancock
In a prior post, I discussed the importance of obtaining long term disability coverage in light of the real possibility that one may become disabled before normal retirement age. In this article, I am going to assume that, because of an injury or sickness, you need to make a claim under that coverage. What preparations should be made to make a successful claim?
- KNOW YOUR COVERAGE, JOB DESCRIPTION AND EMPLOYEE LEAVE POLICIES
As mentioned previously, it is important to obtain and maintain a copy of the policy and any Summary Plan Descriptions (SPDs) relating to Long Term Disability (LTD) coverage that you receive. Don’t wait until you are sick or injured to ask for it. As an attorney, I can get them for you, but it is even better if you already have them. There are a number of reasons for this.
One reason is to know if your coverage is “own occupation,” or “any occupation.” Own occupation coverage is better, as it limits the issue to whether the injury or sickness prevents you from performing the occupation you had been working at.
Your job description helps with this, so it is also a good idea to have a copy of this. Often, job descriptions will list the requirements (physical and/or mental) of the job, which can help you, your doctor, your lawyer and any vocational consultant explain and demonstrate your inability to do that job.
Another reason for obtaining your policy is to know what the “elimination period” is. The elimination period is that period you must be disabled before benefits begin. Why is this important to know?
It has been this lawyer’s experience that some employers won’t remind you of LTD coverage. Since State Disability Insurance (SDI) may pay for a year, the employer might be hoping that you recover within that time and never make a claim under that coverage.
Given that the Family and Medical Leave Act (FMLA), by itself, may only protect you and your position for a number of weeks, knowing your LTD elimination period and your employer’s leave policies can help you figure out if you and your position are vulnerable. Especially since the LTD elimination period may be relatively short (perhaps 60 or 90 days), you certainly may want to make your claim for LTD early on (while you are still employed), so as to protect your right to it and make sure that there is no claim that your coverage “lapsed.”
- MAKE SURE YOU HAVE A SUPPORTIVE DOCTOR – WILLING TO FILL OUT FORMS
In this lawyer’s experience, one of the most important factors in a successful LTD claim is a supportive doctor. In this field, health care records and forms are important and intensely scrutinized and your doctors will be asked, often repeatedly, to fill out forms and/or answer questions.
Having the support of one or more doctors stating that you are disabled and explaining why is important in figuring out if you have a claim and in making a successful one. In light of the importance of physician support, If you get the sense that your doctor(s) and his or her practice(s) are bureaucratic and/or unwilling to fill out forms for you, you may want to investigate changing physicians and/or practices early on, perhaps even before making a claim.
- TREAT REGULARLY
You will want to treat regularly for several reasons Most policies require regular treatment in the obvious hope that you get better. But, additionally, seeing you repeatedly, gives your doctor(s) a good foundation for his, her and/or their opinion(s). Your chances improve when your doctor’s opinions are based on seeing you on multiple occasions over the opinions of an insurance company doctor who has seen you only once, or never.
It is important to remember this, even in the circumstance where your claim is approved, inasmuch as policies allow for and insurers routinely require periodic reports on how you are doing and as to whether you remain disabled, or not. If you have stopped treating, how good is your proof of continuing disability going to be and who is going to fill out your forms, or vouch for you?
- YOU DON’T HAVE TO WAIT TILL YOUR CLAIM IS DENIED, OR TERMINATED TO SEE A LAWYER EXPERIENCED IN LTD MATTERS
Two obvious times you will want to consult with a lawyer are if and when your claim has either been denied, or terminated. Certainly, in such cases you will want to not only see a lawyer, but see him or her early on, in light of possible deadlines for appeals and the importance of “making the record” before the appeal is decided.
But you don’t have to wait till those things happen to see a lawyer. While it has been this lawyer’s experience that many doctors are experienced and good at filling out the kind of forms that insurance companies ask them to fill out, some aren’t. You also have to understand that the insurance companies prepare the forms and that they can be “tricky.” Consulting with a lawyer to review your claim and the forms before they are completed and before they get sent in to the insurance company can help prevent denial, or termination and save you the agony and greater expense of an appeal or lawsuit.
You also should know that successful claims are usually backed by not only supportive medical documentation, but also by vocational information. A lawyer who knows good vocational consultants can help obtain vocational reports and information that make and strengthen your claim where appropriate.
In other words, consultation with a lawyer experienced in LTD matters is another ingredient in the making of a successful LTD claim.
Mark E. Hancock is an Attorney, with offices in Ventura, CA, who is experienced in LTD claims, appeals and lawsuits.