Long Term Disability Benefits: How The Claims Process Works

The long term disability claims process can be difficult, confusing and downright frustrating. Knowing how the process works, what to watch out for and when to contact an attorney can make that process a lot more tolerable.

How the process works

Ron Dean, a California attorney who has been engaged in employee benefits litigation primarily on behalf of participants for over 30 years, sat down with us to explain. Here’s what he told us:

Generally, the person will file a claim with the insurance company or the employer, fill in the forms, fill in the blanks, have their attorney fill in the accompanying attending physician’s statement and then provide evidence of the disability. The insurance company or the employer will then review it and come to a conclusion as to whether they believe it is sufficient to show that you’re disabled. You have to watch out because even though you know you’re disabled, communicating the reasons for that to an insurance company that has to pay money if they find you disabled is not always easy.

You know how much it hurts when you try to walk from the living room into the kitchen. You know how difficult it is to get out of bed in the morning. You know what kinds of problems you’re having, but communicating those to someone who really would rather it not be true is often times difficult. So, my recommendation is to always give them more information than they ask for. Try and imagine if you were on the other side, if you were the insurance company, what kind of information you would want to know in order to say, ‘This person is disabled.’ It’s not just a matter of saying, ‘Hey, I know I’m disabled. I’m sure they’ll agree with me. No one could think I’m other than disabled knowing what I’m going through.’

The doctor’s opinion really matters

The second most important element in the claims process is the treating doctor, according to Dean. “It’s normal for the insurance company to say, ‘Well, what you think is important, but what the doctor says is what’s going to convince us.’ Otherwise, anybody could just raise their hand and say, ‘I’m disabled, I really hurt, Pay me money’ and the insurance company would have to pay the money. So, what the doctor says is critical. If the doctor isn’t willing to back you up, then you’ve got serious problems. The doctor not only has to be able to say you’re disabled, but also has to be able to say why you’re disabled – and the more detail, the better.”

Three main elements of a long term disability claim

Dean says that there are three main elements to a long term disability claim:

1. What is the disease or injury that disabled you?
2. How does that disease or injury result in restrictions and limitations in your ability to work? Those are magic words – restrictions and limitations – things you can’t do and things you shouldn’t do because of your medical condition.
3. How do those restrictions and limitations translate into you being unable to do your job? I may have a restriction or limitation that I can’t raise my arm up in the air, but if I have a sedentary job which doesn’t require that I raise my arm in the air, then I’m not disabled from my job.

Dean says that the doctor has to be willing to certify your disability, give you restrictions and limitations and say how those prevent you from doing your job – as well as tell the insurance company why these things are so. “So often we run into doctors who think it’s enough to say, ‘This person is disabled because I say they’re disabled and that’s all you get to know. You’ve got to take my word for it.’ Believe me; the insurance company will never take their word for it. The doctor has to give the reasons why you’re disabled. Dean provided the following example:

[I]f you say, ‘Well doc, I’m in pain all the time’ and the doctor puts in the report, ‘The patient is in pain all the time and I know this because the patient told me’, the doctor isn’t really adding anything. It’s not the opinion of the doctor; it’s the opinion of the participant, the applicant, which really gets us nowhere at all. The doctor needs to say things like, ‘On my clinical exam, the patient’s complaints of pain were consistent with this disease or that problem and I performed a clinical exam that showed the credibility and consistency of those reports.’

If you’ve been denied valid long term care benefits, consult with an experienced ERISA (Employee Retirement Income Security Act) attorney to discuss your situation and evaluate your options. Consultations are free, without obligation and strictly confidential.