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How Long-Term Disability Is Determined by Physicians and Employers

If you have a long-term disability (LTD) policy through your employer or you have purchased an individual one on your own, you may need it if you ever have a long-term disability. This disability may allow you to continue to receive most of your salary in the event you cannot work.  However, the LTD claim process can be lengthy and time-consuming. Before you can get approved for LTD benefits, you will have to prove, with medical evidence, that you meet your insurance policy’s definition of disability. Your employer may also have certain requirements in the policy about waiting periods, premiums, and a minimum number of hours worked that you need to consider when applying for the LTD benefits.

If you are considering applying for long-term disability benefits, it is important to consult the summary plan description in your long-term disability policy. Typically, you will be found ‘totally disabled’ if you are unable, due to injury or illness, to substantially perform the duties of your job. If your policy provides for ‘partial disability,’ you may qualify for these benefits if you can no longer work full-time at your own job, even if you can work full-time or part-time at another job.

The most important factor in proving your long-term disability is the medical opinion of your treating physician. You will need to communicate with your physician on an ongoing basis regarding your symptoms and your medical complaints. In the process of applying for LTD benefits, your physician will be asked to complete a form or written statement regarding his or her opinion of your condition. This physician’s opinion is important, and his medical opinion may determine your case results. However, the claims administrator will also want objective proof of your disability. He or she will want any medical records related to your disability, including relevant clinic notes, lab results, x-rays, MRIs, surgical reports or other exam findings. Additionally, to prove that your disability is ongoing, you need to continue to receive treatment from your physician while your LTD claim is pending, even after being approved for the LTD benefits. If you fail to continue treatment, this may be grounds for the insurance company to cease your benefits.

There are other requirements for receiving LTD benefits. If you don’t pay your LTD benefit premiums timely, this will cause your insurance to lapse. Also, most employer-sponsored LTD plans require that you are a full-time employee at the time you become disabled. Most employers define ‘full-time’ as working at least 30 or 35 hours a week, but it is best to check with your LTD policy. There also can be waiting periods on LTD eligibility requirements. Most LTD policies have an ‘elimination period,’ or waiting period, between the time your disability occurs and when you can begin receiving benefits. Also, there may be pre-existing condition exclusions in your policy, and you may not be paid for benefits for any long-term disability that comes from that pre-existing condition for the first twelve months of your LTD coverage.   It is also important to check if your illness or injury is covered by your LTD policy, and that your policy does not have exclusions for certain diseases or workplace accidents.