Every day, long term disability insurers make decisions to pay claims or deny them. This article deals with the most common mistakes that you can make when applying for benefits, while you are on claim or if you need to challenge the insurer’s decision.

The Application:

Every long term disability benefit (“LTD”) application involves three documents – the employee/applicant form, an attending physician’s statement and the employer statement.  

The Employee Statement:

This form contains important information which the insurance company requires to set up your claim and consider whether you satisfy the definition of disability required by your insurance policy. Complete this form carefully and proofread it before sending it. It will need to include:

• Identifying details such as your date of birth, full legal name, address and contact information;
• Employment information such as when you became employed, your last day of work, your hours of work and position at your employer;
• Medical information such as a description of your symptoms and functional;
• restrictions/limitations which prevent you from working, treating doctors’ names and treatment you are receiving including medication.

Common errors in the Employee Statement:

• Incomplete or insufficient personal information – this may not ruin your claim but it will cause delay;
• Suggesting the disability is caused by the work environment or a particular supervisor – the insurance company will conclude this is a workplace problem and not a disability;
• Including the diagnosis but no description of how you are functionally limited – think in terms like “what stops me from working”;
• Overly optimistic statements about when you expect to return to work.

Keep a copy of your form so that you can correct any errors or provide updated information if the original form ceases to be accurate.

The Employer’s Statement:

You will have very little control over what the employer provides to the insurer, but it’s important to obtain a copy of the form to see if there are any errors in the form. Common errors in the employer’s form include:

• Date of employment, coverage date and the date you last worked
• Inaccurate job description
• Incorrect benefit or income amount

If the employer provides inaccurate information, you can advise the insurer so that the case adjudicator can follow up with the employer.

The Attending Physician Form:

This form is completed by your main treating physician. If the disability is based on mental health symptoms, a specialized form is required. Your doctor will need to provide a detailed description of your condition including the diagnosis, the symptoms including frequency and severity, medication (both current and medication which has been tried), the names of other treating professionals, response to treatment and prognosis.

Common Errors in the Attending Physician Form:

• Incomplete information about how the diagnosis impacts the employee
• A diagnosis is not enough – insurers want to see that the symptoms cause functional limitations which prevent you from working
• Tying the condition to an unsupportive workplace/supervisor
• Errors summarizing the treatment history
• Insufficient information about medication and current treatment

Keep a copy of your attending physician’s statement. A surprising number of attending physicians’ forms contain inaccurate statements which you will want to ask the doctor to correct. Another problem is that some doctors send the original form to the insurance company, failing to keep a copy for their records.

While Receiving Benefits

If you are approved for benefits, it is important to understand that your insurer has decided that you satisfied the definition of disability when your claim was accepted but they can and will continue to request ongoing medical information which proves that you are still entitled to benefits. 

Your obligations while receiving benefits include:

• Responding to the insurer when they contact you – ignoring the insurer or fighting with them about whether they are entitled to information can ruin your claim and result in termination of your benefits.
• Following recommended treatment – if your doctor has recommended treatment such as medication and you do not take it, make sure that your doctor documents the reason that you cannot follow their advice.
• Attending assessments by doctors they hire – insurers have a right to obtain an independent or third-party assessment of you while you are on claim. It is reasonable to find out the type of doctor and assessment and make sure that your treating doctor agrees that it is appropriate.
• Participating in rehabilitation – most insurance policies allow the insurer to obtain treatment or rehabilitation to assist you in returning to work. This might be psychological treatment or a pain program. If your doctor disagrees that this is appropriate, they need to advise the insurer of their opinion.
• Return to work if you are able – Disability benefits are only payable if you continue to satisfy the definition of disability in your policy. If you can return to work, the insurer will insist that you try (particularly if your doctor has recommended that you return). 
• Participating in a graduated return to work – While you are required to try to work if your doctor thinks you are ready, it is reasonable to have your doctor recommend a gradual return to work. If the insurer suggests a particular schedule, your doctor can suggest that it be modified.

Failing to comply with any of these requirements without medical support for your position will result in a termination of your benefits. Multiple instances of refusing to follow your obligations will ruin your disability claim. The insurer will be legally justified in terminating the claim, even if you are still disabled under the policy.

The Appeal

If your disability claim is denied or a paid claim is terminated, you can tell the insurer that you are appealing their decision. In most cases, you have a choice not to appeal and can start a lawsuit rather than waiting to have the insurer review its decision in an appeal. Some insurance policies require you to appeal before you can sue to enforce your claim. 

Mistakes which can ruin your appeal’s chance of success:

• Emotional or angry statements which insult the decision-maker or suggest that all insurance claims are denied.
• Providing no new information about symptoms or restrictions and simply arguing the same information which resulted in a declined claim.
• Missing the appeal deadline without asking for an extension to provide information. 
• Failing to address the reasons the insurance company denied your claim. The denial letter provides a roadmap for what the insurer thinks is missing. Answering their questions and providing them with more information which they say is missing will be the best way to achieve a successful result.

Litigation

Every denial/termination letter will refer to the limitation period. The limitation date is the date after which you cannot sue the insurer. Missing the limitation period is usually an incurable mistake. If you miss the limitation period, you cannot start a lawsuit except in very limited circumstances.

Conclusion

Contrary to popular belief, insurance companies pay long term disability claims if they are properly supported by medical evidence and enough information to show that the person is functionally restricted from working. An experienced long term disability lawyer can guide you through the claim process so that you can avoid making the common mistakes which will result in a denied claim.