It is sometimes difficult for outsiders to imagine the painful and invisible nature of chronic illness.  The effects on the body, however, are dreadfully real.  The simplicities of everyday life can swiftly develop into tiresome, painful, and lengthy tasks.  Activities, hobbies, or careers that were once treasured can become taxing, strenuous, and some days nearly unbearable. Many illnesses can flare or fade without notice, causing life disruption.  When this happens, you will likely find yourself seeking financial and health-related support.   

Most people have a basic understanding of the health insurance benefits available to them.  Other benefits such as Worker’s Compensation (WC), Social Security Disability Benefits (SSDI), and State Disability (DI) benefits are also commonly thought of and utilized in situations such as this.  Surprisingly, many people don’t realize they have access to another valuable resource through their employer:  Group Long Term Disability insurance. Long Term Disability (LTD) benefits are provided to an individual to replace lost income, in the event of an injury or sickness, resulting in an inability to work. 

LTD benefits, unlike Workers' Compensation, State Disability, or Social Security Disability Income benefits are neither statutorily mandated, nor provided by the government. LTD benefits are either purchased by the individual on his or her own behalf, or they are provided as a benefit of employment. If your illness becomes disabling, utilizing your LTD benefits might provide some financial relief.

How do I know if I have Long Term Disability (LTD) benefits? Or more importantly, who should I ask?  Firstly, find out if you have LTD benefits. For those of you who did not purchase a disability policy independently, the answer is a little bit more complicated.  If your employer has provided you with a package of insurance services, it might not be immediately clear whether or not LTD is included. In this case, you (or your attorney) can send a letter (make it certified so you can track it) to your employer, requesting a Summary Plan Descriptions and all Benefit Plans provided by your employer.  You should know that upon written request, your employer (or the Plan Administrator) is obligated under Federal Law to provide you with information regarding benefit programs within 30 days.

How do I submit a LTD Claim? Once you have a copy of your Summary Plan Description and/or the policy, you can refer to it for the specific claims submission procedures you must follow. The steps for submitting a claim can vary depending on your employer. However, the process usually begins when you contact your employer, or insurer, to tell them that you need to submit a disability claim. You will then be provided with a number of forms to complete and sign for your claim. Make sure that you complete ALL required forms…failure to do so will most likely result in a denial for “failure of proof.”

What types of paperwork should I expect to receive?

  1. Disability Claim Form: state the reasons that you are disabled and identify your treating physicians.
  2. Attending Physician Statement: this will be completed by your treating physician. He/she will state your restrictions and limitations, which prevent you from performing the material duties of your occupation (and the expected duration of your condition).
  3. Employer’s Statement: this will be completed by your employer, identifying your rate of pay and job responsibilities at the time of your ceased employment.
  4. Authorization of Release of Medical Information: this form will allow the Claims Administrator to obtain your medical records.
  5.  Additional Information: take advantage of this opportunity to submit additional documentation in support of your claim.  For example, records from your treating physician that support your diagnosis and disability, a detailed job description which describes your work duties (including the physical and mental demands and the working hours required), a letter from you describing the symptoms of your disability and how this impacts your functional capacity for work and daily living, and letters from family, co-workers, or friends describing their personal observations of your symptoms and how this has adversely impacted you at work and home. 

How should I communicate with the Claims Administrator? All communication with your insurance company should be in writing! All correspondence should be sent through certified mail, return receipt requested. 

What should I do if my claim has been denied? Unfortunately, it is not uncommon for insurance companies to deny a LTD claim.  Under the Employee Retirement Income Security Act (ERISA), you have a legal right to appeal the denial of disability benefits. Begin by requesting your claim file and policy (if you don’t already have it) from your insurance company.  The claim file consists of:  all medical records, reviewed internal notes and memos, outside doctor reviews, surveillance video, and any other information the insurance company used to make a decision on your claim. 

The appeal creates yet another opportunity to provide the insurance company with evidence of your disability.  Gather thorough explanations from your physician, family members/friends, and employer on how your disability has impacted the quality of your daily living.  Also, do not ignore the side-effects of the treatment of your disabilities, and how those impact your ability to work.  The more people you have explaining your limitations and restrictions, and how your life has been adversely impacted by your illness, the stronger your claim becomes.

Make your appeal letter similar to a cover letter, telling the insurance company why you disagree with their decision, and what information they will find in your appeal packet (the information mentioned above) that will change their minds.  Keep in mind that any information you leave out of your appeal may never be heard or considered by a court, so be very careful and very inclusive! Send the appeal through certified mail, fax or e-mail.  

There are time limits governing the claim and appeal process.  According to the Regulations, a claimant has a minimum of 180 days to appeal a denied disability claim. An insurer must decide the appeal within 45 days, or if “exceptional circumstances,” exist, may request an additional 45 day period to decide the appeal.

This process is becoming too complicated for me to manage on my own. What should I do if I need assistance?

Communicating with insurance companies can be a tedious and exhausting venture. The stress from dealing with a Long Term Disability denial only adds to the difficulty of living with chronic illness. If you have questions about your LTD insurance denial, Kantor & Kantor can help.  We offer no cost consultations, and we work on a contingency basis- meaning we do not collect a fee unless we get your claim paid. See our website for more information or call us at (800) 446-7529.

We understand, and we can help.