10 Tips To Maintain Approval Of Your Long-Term Disability Benefits

You should not assume that the insurance carrier will continue to pay benefits indefinitely once your long-term disability claim is approved. Your disability insurance policy may state that benefits are payable until you reach retirement age. However, it does not guarantee that you will automatically continue to be eligible to receive benefits until then.

Disability claim examiners regularly review claims to ensure that you continue to meet the definition of disability. Some insurance companies review claims once a month. Others review claims every 3-6 months or maybe even only once a year. Regardless of how often your claim is reviewed, here are ten tips to help you keep your long-term disability claim approved.

Understand the Definition of “Disability” or “Disabled” Used to Evaluate Your Claim

The most important thing to know is how the policy defines the term “disability” or “disabled.” It is also important to note that the definition of “disability” varies from policy to policy. However, it is typically defined as “an injury or illness that prevents an individual from performing the duties of their ‘own occupation’, or perhaps ‘any occupation.'”

Many “own occupation” policies will switch to “any occupation” after a certain amount of time (usually after benefits have been payable for two years or twenty-four months). When a policy transitions from “own occupation” to “any occupation,” the insurer will typically review the claim to determine if benefits are still payable.

For example, a grade school teacher must be on her feet, educating small children. She walks with them all day to the bathroom, recess, gym, lunchroom, etc. Now, let’s say that our teacher has peripheral neuropathy. This requires the teacher to stay off her feet most of the day. In fact, the teacher must occasionally elevate her legs throughout the day.

Under an “own occupation” definition of disability, she may qualify for disability. However, under an “any occupation” definition, she may still be able to work as an administrator, like a vice principal. She can no longer manage the full responsibilities of a teacher but still has the skills to work at a desk. Therefore, she would not meet an “any occupation” definition of disability.

Understand Time Limitations for Specific Conditions

Most group long-term disability policies have a 24-month limitation on claims arising from mental, nervous, and psychological impairments such as depression, anxiety, and post-traumatic stress disorder. Most policies I have seen include some form of mental illness limitation, although the specific language varies from policy to policy.

Some policies also have a two-year limit on long-term disability benefits for chronic pain conditions such as arthritis and chronic back pain and for medical conditions that are primarily diagnosed based on “subjective” complaints, including chronic fatigue syndrome, neuromusculoskeletal and soft tissue disorders, and fibromyalgia. I have seen a MetLife policy with a 24-month limit on neuromusculoskeletal and soft tissue disorders specifically, except where there is certain objective evidence.

You may be able to maintain approved status beyond one of these limitations, but you must prove that you suffer from another medical condition that prevents you from working.

Complete the Attending Physician Statement Correctly

The Attending Physician Statement (“APS”) is a disability claim form completed by your physician. The form asks about your diagnosis, prognosis, treatment plan, and any limitations or restrictions that may affect your ability to work.

Your physician may not know the answer to questions about your abilities, such as how long you can stand or walk. The best way to ensure your APS is filled out correctly is to schedule an appointment with your doctor. This way, you can answer your physician’s questions while they complete the form.

Treat Regularly with Doctors Who Regularly Treat Disabled Patients

Most disability insurance policies will only pay benefits if you receive appropriate care for your disabling condition. If you do not receive treatment for your condition, the insurance company will assume that you are not disabled. They will say that if you are still disabled, you would have continued to seek medical treatment.

It is also important that your doctor is supportive and willing to complete disability claim forms. Managing a disability claim is stressful but even worse when your doctor refuses to complete the necessary paperwork. You need a doctor who is willing to support your claim, even if that means extra paperwork.

Document All Limitations and Restrictions

How well your doctor documents your restrictions and limitations is critical to your disability claim. Your records should explain why you have certain limitations. For example, your records should state that you cannot stoop because of a herniated disc in the back. Your limitations should also be supported by the medical evidence on record in your claim. For example, include an X-ray or MRI report indicating you have a herniated disc.

Seek Objective Testing If Possible

Objective testing techniques include chemical tests, electrophysiological studies (electrocardiogram, electroencephalogram, etc.), X-rays, MRIs, CT scans, blood tests, and psychological tests. A functional capacity evaluation may also provide objective clinical evidence to prove whether the claimant is physically capable of performing the usual and customary duties of a given occupation.

When objective evidence is unavailable, a long-term disability claim may still be validated with subjective evidence. Subjective evidence primarily includes the patient’s self-reports and the observations of friends and family. Psychological and neuropsychological testing are objective tools that may defeat the insurance company’s position that the claimant is malingering or overstating his or her disabling condition.

Document Activities of Daily Living and How Those Activities Have Changed

Document your daily activities and how they have changed in a statement to the insurance company. What activities can you no longer perform due to your medical conditions? How long do you need to rest after 30 minutes of activity? You need to tell your story in such a way that the insurance company can recognize why you’re unable to work.

Do Not Believe That Once Approved, Always Approved

There is no such thing as “once approved, always approved” in a disability claim. Even if you have made it past the 24-month mark, your insurance carrier will continue to review your disability claim to decide if benefits are still payable. Insurance companies have the right to review a claim as often as reasonably necessary, even as often as every month.

Be Careful About Social Media Surveillance

Insurance companies are increasingly using social media surveillance to terminate long-term disability claims. When your claim is under review, the claims adjuster will review your social media accounts. Use caution when selecting activities, and be careful about using social media to share this information.

For example, Margie has a spine disorder. She suffers from tremendous back pain, and days her symptoms prevent her from even leaving the house. One day, Margie feels good enough to attend a free concert in a park near her home. She only attends for a brief time but shares a photo of her at the park with friends on social media. The insurance company will claim that if Margie can go out with friends, she is well enough to work. Margie knows this is false, and her doctor has encouraged her to stay active. However, the insurance company will use this as an excuse to terminate her disability claim.

Watch Out for Video and Photo Surveillance

Claimants should also watch out for video and photo surveillance. An investigator will sit outside your house, usually for multiple days, and record your activities. They will document whether you drove anywhere, if you were using an assistive device, and if you had difficulty moving.

Video and photo surveillance is most common before an independent medical examination (IME). This is because the insurance carrier knows you must leave your home. Stay vigilant, make sure your activities align with your limitations, and use any assistive devices that have been prescribed to you.

Contact an Attorney for Help If Your Claim for Long Term Disability Insurance Benefits Is Terminated

We assist claimants with the long-term disability appeal process. We also manage the handling of your long-term disability claims after approval by your disability insurance company.

If your insurance carrier cuts off your disability claim, we can help. Ortiz Law Firm is based in Florida but represents claimants nationwide. Call us at (888) 321-8131 to see what we can do to help you maintain approval of your long-term disability claim.