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Ten Things to Know Before You File a Claim for Long-Term Disability Insurance Benefits

1. Make Sure You Have a Complete Copy of Your Plan/Policy The first step when making a claim for long-term disability insurance benefits is to secure a copy of your policy. If your employer provided your insurance coverage, request a full and complete copy of your policy from Human Resources. Make sure you get a complete copy of the plan/policy, not just the Summary Plan Description. If you purchased your policy directly from the insurance company, or through an insurance agent/broker, you probably already have a copy of your policy with the application attached. If you cannot locate it, contact the agent/broker and/or the insurance company to request a copy of the policy.

 

2. Be Aware of all DeadlinesMany insurance policies contain deadlines requiring you to submit your claim within a certain period of time. It is important to be aware of these dates so you do not inadvertently waive your rights to benefits. In fact, you should try to make your claim as soon you realize that your disability prevents you from working to make sure that you do not accidentally miss a deadline.

3. Become Familiar with Your Policy’s Definitions/ProvisionsEvery disability insurance policy/plan is different. Be sure to read your policy/plan so that you are familiar with its terms. This will help you figure out what information you will need to provide to the insurer to support your claim for disability insurance benefits. The policy/plan will also include the definition of “Disability” or “Total Disability” that the insurance company will use to evaluate your claim. You will want to review policy/plan provisions so that you know some of the following:

  • What are your total policy/plan benefits and how are they calculated?
  • What is the elimination period?
  • What are limitations on policy/plan benefits?
  • Are there offsets to your policy/plan benefits and if so, what are they?
  • What are the exclusions to coverage?

4. Request and Complete All Claim Documents – After you identify to whom you must submit your claim, you need to request and complete all of the claim documents/forms. This typically includes forms to be completed by you, your employer, and your medical health professional(s). It is very important that you promptly complete all of the documents and make sure they are submitted to the insurer. If you fail to complete all the required documents, the insurance company will likely deny your claim citing “lack of information,” regardless of the strength of your disability claim.

5. Gather Your Medical Records and Make Sure Your Medical Health Professional(s) Support Your Disability – When you decide to make a claim for disability insurance benefits, the most important documents you will submit to the insurance company are your medical records and the opinions of your medical health professional(s). The insurer will evaluate your records to determine whether it believes you are capable of performing your job duties in spite of your medical condition, diagnosis and restrictions and limitations. It is therefore important not only to make sure that you send the insurance company all of your medical records that support your claim, but also that your medical health professional(s) agrees that your condition prevents you from returning to work. If your medical health professional(s) thinks you can work is some manner, then the insurance company is very likely to follow their opinion and deny your claim. Make sure your medical health professional(s) understand your material and substantial occupational duties so they can correctly evaluate whether you can work and for how long.

6. Make Sure You Provide a Clear Explanation as to How Your Disability Prevents You From Returning to Work – Your claim for long-term disability insurance benefits depends on your being able to demonstrate that your medical condition, and associated restrictions and limitations, prevent you from performing your job duties. It is therefore important that you are able to explain to the insurance company why you can no longer work. For example, if you suffer from migraine headaches, you should explain that the headaches make it difficult for you to concentrate. Or if you have a back condition that prevents you from sitting for an extended period of time or lifting things, you must make that clear to both your doctors and the insurance company. You must give the insurance company a reason to approve your claim for benefits, and simply saying “I cannot work,” is not enough. You must be able to specifically explain why you are unable work.

7. Determine Whether You Want to, or are Required to, File For Social Security Disability Benefits, State Disability Benefits and/or Workers’ Compensation Benefits – Some policies require that you apply for Social Security Disability benefits, State Disability benefits and/or Workers’ Compensation benefits, if applicable, because they can take offsets for such benefits. You can be penalized with a reduced benefit payment if you do not comply with these provisions, so make sure to apply for these benefits if required.

8. Determine if You Have Short-Term Disability Coverage – All disability insurance policies have an “Elimination Period,” which is the time period between an injury and the receipt of benefits. In other words, it is the length of time between the beginning of an injury or illness and receiving benefit payments from an insurer. It is sometimes referred to as a “waiting” or “qualifying” period. Elimination Periods can be as long as 180 days, but if you have short-term disability insurance you should be able to receive benefits during the Elimination Period.

9. Know What Law Applies to Your Disability Claim Which law applies to your disability claim depends on how you obtained your policy. If your employer provided your insurance coverage, it is more likely than not that your claim will be governed by a Federal law called ERISA, which stands for the Employee Retirement Income Security Act of 1974. If you purchased your policy directly from the insurance company, your claim will likely be governed by State law. If your claim is denied, your damages and potential remedies will likely be larger under state law, because you can sue the insurance company for past due and future benefits, as well as for bad faith (also known as a breach of implied covenant of good faith and fair dealing). The remedies available under ERISA are limited to past due benefits, and possibly attorneys’ fees if you prevail in your lawsuit.

Additionally, if your claim is governed by ERISA, then the plan’s language and definitions will control. However, if your claim is not governed by ERISA, but is governed by California’s or some other state’s laws, you should know this. If state law governs, you may be able to disregard the definition of total disability in your policy and use the applicable state law definition. This is especially true in California where the law is very friendly to consumers. Very often, we see insurance companies incorrectly use the definition of total disability, which can be outcome determinative to your claim. If you are not sure if your claim is governed by ERISA or state law or if you are not sure what legal definition of total disability applies to your claim, you should contact an experienced attorney.

10. Be Careful What You Post on Social Media Sites – Insurance companies have begun to check their claimant’s social media posts to see if they are acting in a way that is inconsistent with their claimed restrictions and limitations. While everyone likes to put their best foot forward on social media, if your Facebook or Twitter posts (writings or photos) conflict with your claimed restrictions and limitations, the insurance company may use your own words or photos as a basis to deny your claim. If you feel you must regularly update your Facebook or Twitter accounts, set them to private, do not accept friend/follower requests from anyone you do not know and be very careful about what you post.

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Address: 20321 SW Birch St. Suite 200
Newport Beach, CA 92660

Phone: 800-682-4137

We also have offices in Los Angeles, San Diego and San Francisco.

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