If you have long-term disability (LTD) insurance and suffer an illness or injury that leaves you unable to work, the last thing you'll probably want to do is deal with your long-term disability carrier—and for good reason. LTD insurance companies are notorious for denying well-supported disability claims by saying your medical evidence is incomplete, your doctors' reports are biased, and a host of other dubious reasons. The problem is perhaps most acute at the initial level of an LTD case, where many insurers reject claims almost automatically and sometimes leave the impression that the case was hardly even looked at before a denial was issued.
While the Employee Retirement Income Security Act of 1974 (ERISA) was designed to protect employer-provided benefits including LTD insurance, insurance companies have learned how to use ERISA as a shield to protect them from paying deserving claims. Here are a few points to keep in mind when dealing with your insurance company or plan administrator.
Request the LTD Policy
Before even filing your disability claim, request a copy of the plan documents (the entire policy) and the summary plan description from your human resources department, plan administrator, or insurance company. Like all correspondence with your insurer, the request for documents should be sent via certified mail with return receipt requested. Insurance companies misplace important paperwork all the time; don't let it happen to you.
When you get the application, look at the eligibility requirements, such as the minimum number of hours required and how long you must have worked for the company, the length of the elimination period, and any policy exclusions (such as pre-existing or self-inflicted injuries). For more information, see Nolo's article on common LTD policy terms.
Use Your Application to Convince the Company
When filling out paperwork, remember that the disability application provided by your insurance company might be designed to elicit answers that could form the basis for a denial. Answer all questions truthfully, but completely; if there isn't enough room for you to explain your impairments or answer a question fully, attach separate pages where appropriate. If you have "good days and bad days," be sure to point that out.
Get Things in Writing
When interacting with your claims representative or any other insurance company personnel over the phone, keep a written record of whom you spoke with, what you discussed, and when the call took place. When your insurer provides you important information over the phone, don't be afraid to ask, "Can I get that in writing?"
Likewise, don't rely on the word of the human resources professionals in your office. While they probably mean well, they're unlikely to be well-versed in the specifics of your long-term disability policy. When in doubt, get it in writing.
Watch What You Say and What You Do
It's important to maintain a healthy skepticism in all interactions with your insurance company or plan administrator, because the slightest, most innocent remark could spell trouble for your claim. For instance, try not to make calls to your insurer from anywhere other than your home. If the person on the other end hears noise in the background (like the sound of a car, shopping mall, or children on a playground), it could be used against you (to show that you can work).
Similarly, many insurance companies have fraud detection departments that conduct video surveillance of disability applicants, so do not perform any activities that are restricted by your doctor. The old saying that "it's not paranoia if they're really out to get you" could have been coined with an LTD insurer in mind.
Beware Insurance Company Doctors
After you file a claim, a number of insurers will require you to attend a consultative examination with a supposedly "independent" physician. In many cases, these doctors perform only perfunctory examinations and write reports indicating that you're either exaggerating your symptoms or making them up altogether. If you aren't sent for a consultative exam, a physician employed by your insurer will review your medical records and, more often than not, decide that your allegations are not supported by the medical evidence.
Make Your Consultative Exam Count
Before attending a consultative examination arranged by your insurance company, consider making a list of the ways your impairments affect you on a daily basis. Are you able to go shopping, cook meals, take showers, or walk up and down steps? Use this list at the appointment to remember all of your limitations. If you fail to mention that you're having difficulties in a certain area, the doctor will presume that you have no restrictions.
Do not attempt to fake or exaggerate the severity of any your medical issues, as doctors are trained to look for this. (Some of them, particularly those working for insurance companies, can even detect it when you're not "malingering" or exaggerating!)
Finally, when you go to your consultative exam, take note of the time your exam began and when it ended. It's surprisingly common for exams to last for as little as ten or fifteen minutes, but this fact is usually not reflected in the doctor's report.
Ensure the Company Has Key and Up-to-Date Medical Records
Insurance companies will generally request your recent medical records at their expense, but unfortunately they often fail to request or obtain important records. Ask your insurer what records are being used to decide your case, and let them know if anything relevant is missing. Also keep your carrier up-to-date on what medical treatment you're currently receiving so it can update your records as needed.
Hire an Attorney to Protect Your Rights
Whether you're thinking about filing an LTD claim or have already been denied LTD benefits, consider hiring an experienced ERISA attorney. Your attorney will interact with the insurance company on your behalf, meet the policy's deadlines, supplement your file with favorable evidence, and handle any settlement negotiations. If necessary, he or she may also file a lawsuit against you insurance company in federal court. Most ERISA attorneys will not charge a fee unless you win your case. Arrange a free consultation with an ERISA attorney in your area.