DO YOU HAVE COVERAGE FOR LONG TERM DISABILITY BENEFITS?
If you are employed by an employer that offers group benefits you may be covered by a policy that contains long and/or short term disability benefits. In addition if you are self employed you may have purchased your own disability insurance policy. Some people even have both.
To discover if you have access to long term disability benefits or short term disability benefits you can speak to your insurance company’s human resources department who should be able to assist you in explaining your rights or provide you with a number to contact the insurance company directly.
You may have been given a benefits booklet at the start of your employment which would also explain the various insurance benefits you are covered for and explain critical information such as the deadlines for applying, the length of the waiting period, and the test for disability which you much meet to qualify.
If you have ascertained that you have long term disability benefits how do you know if you meet the insurer’s test for qualification?
WHAT SORT OF DISABILITIES QUALIFY FOR A BENEFIT?
Every policy of insurance defines “disability” or “total disability “ in a different way. The definition being used in your specific insurance policy will be written in the policy and usually also described in your benefits booklet.
Most policies cover both physical and psychological injury and/or illness. Most policies attempt to exclude injuries or illnesses that existed prior to you becoming an insured under the policy however.
Many policies require that you have been both diagnosed with a disability and are being actively treated for it.
Many polices use a two part definition which allows someone to qualify for the benefit if they meet a partial disability test during the first two years or disability but requires a more severe level of disability to continue getting the benefit following the first two years. Every policy is slightly different in the way they differentiate these two periods. A common way is for the policy to allow for the benefit if an insured is partially or fully incapable of performing their occupation and its duties and only allows for the benefit to be paid past year two if they are fully incapable of performing “any” occupation.
Case law usually requires the “any occupation” test to be interpreted as meaning any substantially gainful occupation which the insured is reasonably qualified for by way of education and work experience.
WHAT DOCUMENTATION IS NEEDED TO APPLY FOR LONG TERM DISABILITY?
Most disability insurance policies use their own application forms. There will usually be two basic forms. An application form will have to be completed by the disabled person describing some background information about themselves, their education, occupation, their disability and the treatment and medical practitioners they’ve been seeing. In addition a disability confirmation form is commonly used, to be completed by the insured’s doctor describing the condition, why its disabling, and what treatment is underway. Such a form may ask the doctor for their opinion on the length of disability that is expected.
In addition to these forms any medical records and reports that support the diagnosis and the opinion that the insured is in fact disabled are able to be forwarded on to the insurer. It is often advisable to get a specific report from the lead medical practitioner specifically setting out the opinion that the insured is totally disabled from their occupation, or any occupation.
WHAT HAPPENS NEXT AFTER APPLYING?
After the application and the supporting documentation has been sent in claims managers at the insurance company will review the application. Often they will use their own internal medical experts, nurses, doctors, or other specialists, to review the evidence and advise on whether the application should be accepted or not.
Sometimes, but rarely at the application stage, an insured maybe asked to submit to an in-person or virtual medical assessment by the insurer’s medical experts.
Then a decision is made to accept or deny and is communicated to the insured.
WHAT IF YOU ARE DENIED LONG TERM DISABILITY?
If you are denied there is almost always an internal mechanism of appeal, usually with a deadline. The appeal can be requested by a simple written request and the application is then reassessed sometimes by a different claims handler.
Why might you be denied? Usually, it is a lack of medical records which fully describe the nature and extent of disability that gets claims denied. A simple report describing a person’s medical diagnosis is often not enough to qualify for disability if it does not explain how that diagnosis is so significant that it prevents a person from not being able to fulfill their work place duties.
How Can FDT Law Orillia Disability Lawyers help?
FDT Laws Orillia long term disability lawyers can help by having a trained legal professional review your disability claim application and determine where the evidentiary holes are that need to be filled to have you qualify. If a denial is upheld. FDT Laws Orillia long term disability lawyers can gather the evidence needed by referral to the appropriate medical experts and if necessary issue a legal action to make sure your rights under the disability policy are respected.