Filing a long-term disability (LTD) claim can be an overwhelming process. Even individuals familiar with other related areas of law like Social Security Disability (SSDI) and worker’s compensation are often surprised at how LTD benefits are structured and how many parts of the process work. Insurance carriers rely heavily on policy language and legal standards that favor them, and what may seem straightforward at first often becomes complex once the fine print is applied.
At Hawks Quindel, our long-term disability attorneys help clients across the United States understand their policies and protect their rights. Below are five of the most common surprises claimants encounter in LTD claims.
1. A Doctor’s Opinion May Not Be Enough
Many people believe a physician’s statement confirming disability will be sufficient to qualify for LTD benefits. In practice, insurers typically require much more. Medical records, diagnostic testing, and other objective evidence are often necessary. A short note from a doctor, even if it clearly states the claimant cannot work, is rarely enough to secure approval.
2. Benefits May Not Last as Long as Anticipated
Claimants are often surprised to learn that LTD benefits do not necessarily continue until retirement age, at least not without some advocacy. Even if your claim is approved, the LTD carrier will continue to ask for medical updates regularly and could deny your claim at any point if they’re not convinced that the evidence supports ongoing disability. Furthermore, many policies shift from an “own occupation” definition of disability to an “any occupation” standard at the two-year mark, making this a common point that claimants face denials. At the “any occupation” stage, claimants must show not only that they cannot perform the job they were doing prior to their disability but also an alternative job. Lastly, many LTD policies limit benefits for mental health conditions to 24 months or less and some may apply a limitation to other conditions as well.
3. Benefits May Be Offset by Other Income Sources
Another common issue is LTD offsets, which reduce monthly benefits based on other income. Offsets often include SSDI payments, pensions, or even part-time wages. These offsets not only decrease the ongoing LTD benefit amount, but also can create significant repayment obligations. For example, when a claimant receives a lump-sum SSDI backpay award, the insurer may demand repayment of LTD benefits already issued, sometimes in the tens of thousands of dollars. Always consult the terms of your policy carefully to understand how these offsets work.
4. LTD Benefits Might Be More Difficult to Obtain Than SSDI
Although SSDI is known for its rigorous standards, LTD benefits can actually be even more challenging to secure in some cases. SSDI claims are analyzed under a more favorable standard for older claimants, meaning that many older claimants in particular are approved for SSDI but still denied LTD. The “any occupation” provision in LTD policies often requires proving inability to do even alternative sedentary work, which can be a tougher hurdle than the claimant may have faced in their SSDI case. Additionally, a hearing in front of a judge can increase your chances of getting SSDI benefits because you are able to provide direct testimony in front of a judge who can speak with you directly, while LTD cases typically do not provide that opportunity (see below.)
5. It Can Be Tough to Win in Court
If your claim is governed by the Employee Retirement Income Security Act (ERISA) as most employer-sponsored plans are, your claim will likely face some increased difficulties if you have to go to court against the insurer. Most cases will be assessed under the “arbitrary and capricious” review standard, which stacks the deck against claimants in a few ways including deference to the insurance company’s decision, reliance on the written record (limited or no discovery, generally no trial), and limited remedies for claimants.
See Attorney Jessa Victor’s blog post, “An Uphill Battle: Understanding the ‘Arbitrary and Capricious’ Standard of Review” for a more detailed discussion of this aspect.
How an LTD Attorney Can Help
The LTD system is more complicated than most claimants expect, and even strong claims are often denied. Each policy has its own terms, and insurers focus closely on whether the medical and vocational evidence lines up with those requirements. Misunderstandings in this process can lead to serious financial consequences. Working with an experienced LTD attorney can help you avoid common pitfalls, strengthen your claim, and protect the benefits you deserve.
At Hawks Quindel, our Long-Term Disability lawyers regularly help clients:
- File strong initial claims
- Appeal LTD denials
- Handle litigation and settlement negotiations with the insurance company
- Understand offsets and policy language questions
If you are considering filing a claim, appealing an LTD denial, or simply need guidance about your policy, our attorneys are here to help.
Contact Hawks Quindel today to schedule a consultation with an experienced LTD attorney.