Applying for Long-Term Disability Insurance Benefits: What to Do and Expect
Applying for long-term disability insurance (LTDI) benefits can be stressful, not only because you are dealing with a medical problem keeping you out of work, but also because communicating with your LTDI insurance company may be challenging. Knowing the process can help reduce stress and ensure the insurance company is not dodging deadlines it must follow.
Talk to Your Doctor(s)
Before submitting your application, talk to your doctors (including any specialists you’re seeing for your disabling condition) to make sure they understand how and why their professional opinions are important to your long term disability application. They will likely be required to describe your diagnoses, symptoms, and restrictions and provide this information to the insurance company when you apply for benefits. It is important to have a treating provider who agrees your medical conditions are preventing you from working and is ready to offer supporting evidence.
In addition to completing the forms required for the application, you may also include a personal statement written by either yourself or your close family members to describe your medical situation in more detail, and how it interferes with your ability to work. Such personal narratives provide context for your injury and work history that may not be obvious or evident through your physicians’ reports. Your goal is to thoroughly communicate how your injury affects your life and work; nobody knows this better than you and your loved ones.
Expect a Waiting Period with Possible Extensions
Once you’ve submitted your application, the waiting game begins. If your LTDI insurance plan is covered by the Employee Retirement and Income Security Act (ERISA) – which is very common for private employers – the insurance company must decide your claim within a maximum of 105 days. The insurance company has additional deadlines within this timeframe:
- First, within 45 days of receipt of your claim, the insurance company must notify you of either its claim decision or its need for an extension of up to 30 days.
- The insurance company may invoke another 30 day extension (for a total of 105 days) so long as it follows these procedures before the expiration of its first extension.
- The insurance company must get your agreement for any further extensions.
What are acceptable reasons for the insurance company to invoke an extension? The reason must be due to matters beyond the insurance company’s control and be explained in writing. Typically, we see extensions invoked to gather medical records, have a physician or nurse case evaluationant review the evidence provided, or conduct an independent medical examination.
If an insurance company requests an extension to gather additional information, it may also tell you the review period is “paused” between the date it asks you for additional information and the date you respond to that request. Occasionally, we see insurance companies make several requests for information a few weeks apart, which maximizes the delay in deciding your claim or appeal.
Appealing a Denial of LTDI Benefits
Hopefully, you receive a favorable decision on your claim. However, if you do not, you have the option of appealing a denial of benefits. Under an ERISA plan, you have 180 days from the denial to submit your appeal. The denial letter must tell you about this deadline and inform you about the specific reasons for the denial, the plan provisions on which it was based, and any additional material or information you should submit with your appeal. The denial must also explain why the insurance company disagreed with your doctors and the opinions of any medical professionals it case evaluationed.
In addition to any information outlined in the denial letter, you should submit detailed documentation from your treating providers about why your medical conditions prevent you from working with your appeal. Ask your doctors to read the denial and respond specifically to any medical disagreements in the denial explanation. Again, you can also submit additional personal statements describing your disabling conditions and explaining why the denial decision was incorrect. When we assist clients with appeals, we also outline the legal reasons the denial should be overturned.
More Waiting After an Appeal
When waiting for a decision on your LTDI benefits appeal (as opposed to an initial claim), the insurance company has the same 45-day window within which it must give you a decision or invoke an extension. After that, the insurance company can only invoke one more 45-day extension before it needs your agreement to extend the decision deadline further. Thus, appeal decisions must come within 90 days of receipt of your appeal.
Contact an Attorney to Discuss Your Case
If you have any questions about the LTDI benefits application process or believe your benefits have been wrongfully denied, feel free to contact us and one of our benefits attorneys will review your situation.
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