At Aaron Engle Law (AEL) our objective is to help our clients put their lives back on track. We understand that dealing with insurance company antics is the last thing you need if you’ve been gravely injured or are dealing with a long-term disability claim.
Obtaining long-term disability benefits can be a challenging and unpleasant procedure. Policyholders frequently struggle to determine which medical illnesses are covered, which are not, and how severe symptoms must be before the insurance company will approve the claim.
What Exactly Is Disability Insurance?
Disability insurance is a form of insurance product that provides an income if a policyholder is unable to work or earn an income due to a disability.
Disability insurance makes payments directly to you, allowing you to cover your expenditures with no restrictions on how you spend the money. It is important that you read the plan summary for definitions describing what is covered as well as details required by your plan.
In general, long-term disability insurance policies will employ one of two definitions of disability:
- Own occupation: An own-occupation policy covers you if your symptoms prevent you from meeting the work duties of the current employment that you are trained to perform. You can change your job and still obtain total disability payments.
- Any occupation: To be eligible for any-occupation coverage, your symptoms must render you completely handicapped and unable to perform any work for which you are qualified.
This is a far more stringent threshold than an own-occupation policy. The any-occupation definition can lead to benefits being denied and claimants being compelled to accept lower-paying, less satisfying jobs.
The any-occupation standard is used by most long-term disability insurance companies. It is strongly advised you acquire any-occupation coverage if you have the choice, especially if you work in a highly skilled job.
How Does Disability Insurance Work?
In the case of disability insurance, this reimbursement is for lost income because of a disability, whereas insurance products cover you from a specific loss, such as when a property and casualty insurance policy reimburses for the value of the stolen property. Short-term disability and long-term disability are the two basic types of disability insurance. Short-term disability can linger up to two years. Long-term disability commonly begins after short-term disability and can continue a person’s entire life.
Long-term disability insurance provides salary replacement of 50-70% of your earnings before a non-job-related injury affects your capacity to work. Long Term Disability policies differ in terms and circumstances, but perhaps the most significant distinction is that, whereas long-term disability insurance can be acquired individually through an insurance company, most long-term disability plans are sponsored by an employer.
In practice, a policyholder must meet several conditions to get these benefits. Disability insurance plans, like all types of insurance, will have higher premiums if their terms and conditions are more favorable to the policyholder.
Why Do I Need Long-Term Disability Insurance?
Would you be able to afford your living expenses and any additional medical bills if you lost your income due to an injury or illness? Most people say no. And, because Social Security payments are often smaller than your regular income, it’s critical to have additional safeguards in place to ensure your finances stay on track even if you suffer an unforeseen illness or injury.
What Is Covered by My Long-Term Disability Policy?
Long-term disability insurance coverage generally covers any disability that:
- Fits your policy’s definition of impairment
- Is not specifically excluded by your policy
Unlike Worker’s Compensation, long-term disability insurance offers compensation whether your injury or illness is related to your job or not. Long-term disability often pays a larger benefit than Social Security Disability Insurance and has a better possibility of being covered. If you are unable to work due to cancer, an accident, or a critical illness, you can supplement your long-term disability payments with supplemental cancer, accident, or critical illness insurance.
Medical Conditions That Could Be Eligible for Long-Term Disability
It is hard to establish a comprehensive list of possibly disabling conditions because there is no master list of qualifying conditions that can be certified for long-term disability. Some of the most prevalent medical problems that may qualify for long-term disability are listed below.
These circumstances frequently make it difficult to secure or keep a gainful job. As a result, a person may be entitled to disability benefits. When you claim long-term disability payments, you must demonstrate that you are disabled (as defined by your policy) and unable to perform meaningful employment.
A neurological condition is a disease of the brain, spinal cord, nerves, and muscles that affects both the central and peripheral nervous systems. These include, but are not limited to, the following:
- Peripheral neuropathy
- Bell’s Palsy
- Alzheimer’s disease
- Guillain-Barre Syndrome
- Lou Gehrig’s Disease or Amyotrophic Lateral Sclerosis (ALS)
- Neuropathy (often, Peripheral Neuropathy)
- Multiple Sclerosis (MS)
- Parkinson’s Disease
- Seizure Disorder
- Traumatic Brain Injury (TBI)
Mood changes, thought processes or behavior, are common symptoms of mental health issues. These include, but are not limited to, the following:
- Bipolar disorder
- Post-traumatic stress disorder
- Personality disorders
- Neurocognitive disorders
- Obsessive-compulsive disorder
- Sleep disorders
Chronic conditions are widely characterized as conditions that persist over a length of time and require continuing medical management. These include, but are not limited to, the following:
- Chronic lung disease
- Kidney disease
- Heart disease
A degenerative disease is one in which the structure of an organ’s tissues and cells deteriorates over time. These include, but are not limited to, the following:
- Huntington’s disease
- Parkinson’s disease
Heart disease and related ailments are categorized as “cardiovascular,” which refers to the heart, blood vessels, and related systems. These include, but are not limited to, the following:
- Aortic Aneurysm
- Chronic Venous Insufficiency
- Coronary Heart Disease
- Chronic Pulmonary Hypertension
- Heart Attack/Heart Failures
- Ischemic Heart Disease
- Peripheral Artery Disease (PAD)
Hematologic diseases are conditions that affect the blood and the organs that produce blood. These include, but are not limited to, the following:
- Aplastic Anemia
- Chronic Anemia
- Chronic Granulocytopenia
- Chronic Thrombocytopenia
- Coagulation Defects and Hemophilia
- Hereditary Telangiectasia
- Polycythemia Vera
- Sickle Cell Disease
Cancer develops when cells divide uncontrolled and spread into neighboring tissues. Cancer is caused by DNA alterations. These include, but are not limited to, the following:
- Cancer, including Blood, Bone, Breast, Colon, Esophageal, Gastric, Kidney, Lung, Liver, Ovarian, Pancreatic, Prostate, Skin, Thyroid Cancer
- Hodgkin’s Disease
- Multiple Myeloma
The following list includes conditions that affect the immune system. These include, but are not limited to, the following:
- Connective Tissue disease
- Allergic Reactions
- Immune Deficiency Disorders, such as Ataxia-telangiectasia, Chediak-Higashi syndrome, Chronic Fatigue Syndrome, DiGeorge syndrome, Hypogammaglobulinemia, Leukocyte adhesion defects, Bruton’s disease, Selective deficiency of IgA, Wiskott-Aldrich syndrome, Lupus
- Poisoning or Chemical Sensitivity
- Multiple Sclerosis
- Inflammatory Arthritis
Musculoskeletal disorders are conditions or injuries that affect the tendons, spinal discs, cartilage, nerves, joints, muscles, and bones, among other things. These include, but are not limited to, the following:
- Bone Fractures (ie. Leg/Femur, Hip/Pelvis, etc.)
- Carpal Tunnel Syndrome
- Chronic Neck or Back Pain
- Degenerative Disc Disease or Degenerative Joint Disease
- Herniated Disc
- Muscular Dystrophy
- Reflex Sympathetic Disorder
- Rheumatoid Arthritis
- Ruptured Disc
- Spina Bifida
- Spinal Arachnoiditis
- Spine Disorders
- Stenosis (Cervical, Lumbar, etc.)A form of respiratory disease that affects the lungs and other elements of the respiratory system. These include, but are not limited to, the following:
A form of respiratory disease that affects the lungs and other elements of the respiratory system. These include, but are not limited to, the following:
- Chronic Lung Infections, including Mycobacterial and Mycotic
- Chronic Obstructive Pulmonary Disease (COPD)
- Chronic Restrictive Ventilatory Disease
- Cystic Fibrosis
- Lung Transplant
A sensory impairment occurs when one of the senses – sight, hearing, smell, touch, taste, or spatial awareness – does not function properly. These include, but are not limited to, the following:
- Meniere’s Disease
- Hearing Loss or Tinnitus
- Loss of Speech
- Vision Loss or Disorders, including Diabetic Retinopathy and Macular Degeneration
A digestive disease is any medical condition that affects the digestive tract. These include, but are not limited to, the following:
- Cirrhosis of the Liver
- Gastrointestinal Hemorrhaging
- Crohn’s Disease
- Inflammatory Bowel Disease (IBD)
- Irritable Bowel Syndrome (IBS)
- Kidney Failure
- Chronic Liver Disease
- Liver Transplants
- Short Bowel Syndrome
- Wilson’s Disease
- Primary Biliary Cirrhosis
- Whipple’s Disease
- Wilson’s Diseases
The endocrine system regulates how our bodies work. Hormones are produced by endocrine glands and released into the bloodstream, where they travel to various organs throughout the body. Conditions include, but are not limited to, the following:
- Pituitary Gland Disorders
- Thyroid Gland Disorders
- Parathyroid Gland Disorders
- Adrenal Gland Disorders
- Pancreatic Gland Disorders
Hematologic illnesses are blood disorders that affect red blood cells, white blood cells, platelets, bone marrow, lymph nodes, and the spleen. These include, but are not limited to, the following:
- Chronic Anemia
- Sickle Cell Disease
- Chronic Thrombocytopenia
- Hereditary Telangiectasia
- Coagulation Defects
- Polycythaemia Vera
- Chronic Granulocytopenia
- Aplastic Anemia
Infections and Parasitic Disorders
A variety of infections and parasitic diseases, if severe enough, may qualify for long-term disability benefits. These include, but are not limited to, the following:
- Epstein-Barr Virus
Urinary and genital organs are affected by genitourinary disorders. The kidneys, ureters, bladder, and urethra are all urinary organs. Conditions include, but are not limited to, the following:
- Impairment of Renal Functions
- Nephrotic Syndrome
- Pregnancy-Related Complications
A wide variety of skin problems, if severe enough, may qualify for long-term disability benefits. These include, but are not limited to, the following:
- Bullous Diseases
- Chronic Infection of the Skin or Mucous Membranes
- Genetic Photosensitivity Disorders
- Hidradenitis Suppurativa
Multiple Body System Impairment
Various diseases and disorders that impact multiple body systems qualify for long-term disability. These include, but are not limited to, the following:
- Mosaic/Non-mosaic Down Syndrome
- Trisomy X Syndrome
- Fragile X Syndrome
- Caudal Regression Syndrome
- Fetal Alcohol Syndrome
- Reye’s Syndrome
- Ehlers-Danlos Syndrome
Symptoms, Signs, and Subjective Conditions
There are certain symptoms, signs, and subjective conditions that if severe enough qualify for long-term disability. These include, but are not limited to the following:
- Chronic Fatigue Syndrome
- Chronic Radiation Enteritis
- Seasonal Affective Disorder
- Sleep Apnea
- Sleep Disorder
If your disorder does not fall into one of these categories, it does not always rule you out of receiving disability compensation. It simply implies that because your disability cannot be evaluated directly, a representative must assess how your condition affects your capacity to do ordinary work-related tasks. As each insurance is unique and most plans are extremely complicated, working with a long-term disability attorney to file a claim is your best option.
Conditions That Automatically Qualify
In most cases, a disability insurance provider will thoroughly investigate your claim before determining your eligibility and require sufficient evidence. However, there might be disorders that are so visibly disabling that they may immediately qualify for approval under your insurance coverage. If one of these conditions has rendered you incapacitated, you will not be required to demonstrate your injuries’ extent, nature, or impact. Typically, automatically qualifying requirements include:
- Complete deafness
- Complete blindness
Keep in mind, however, that policy phrasing might vary greatly.
Exclusions and Limitations
Certain conditions might be excluded from your long-term disability policy. The most common limitations and exclusions are:
- Alcohol abuse
- Pre-existing medical conditions
- Certain mental health conditions
- Certain self-reported conditions or illnesses
- Workplace injuries
- Substance abuse
Your policy may include other limitations and exclusions. You must familiarize yourself with your long-term disability policy.
Why Would Long-Term Disability Benefits Be Rejected?
For a variety of reasons, long-term disability claims may be dismissed. The following are some of the most common causes of rejection:
- The claim was not submitted on time.
- If the insurance company attempts to communicate many times and receives no response, they may deny or cancel benefits because of the failure to communicate.
- A contractual exclusion may cause an insurance provider to withhold coverage. The “pre-existing condition exclusion clause” is one of the most prominent justifications for dismissing claims based on a contractual exclusion.
- Insufficient evidence was submitted to support the diagnosis. A diagnosis alone is often inadequate to provide the insurance company with enough evidence to evaluate if the claimant meets the disability test under the long-term disability policy.
- No objective evidence is available.
- Refusal to attend an independent medical evaluation.
- If a claimant refuses to consent to appropriate medical treatment, his or her benefits may be rejected or terminated.
- Failure to return to work or partake in rehabilitation.
- Under the provisions of the policy, your condition is considered pre-existing.
If your long-term disability benefit was rejected or denied, contact an attorney who specializes in disability claims to assist you with an appeal.
How a Long-Term Disability Attorney Can Help
The approval process for long-term disability can be difficult and frustrating. Sometimes, for policyholders the interpretation of the policy documents is overwhelming, and figuring out what medical conditions are covered and excluded can be difficult. The easiest approach to determine if a certain disability is covered is to have your insurance policy reviewed by an experienced long-term disability lawyer such as Aaron Engle Law.
We will gladly set up a free consultation with an Aaron Engle Law attorney. With our extensive legal experience, we can frequently assist customers in discovering legal possibilities that they were not even aware existed. We’ll listen to the circumstances of your case, sort through the insurance, and assist you in developing a strategy to obtain the compensation and benefits you require. Contact us today!
This is not intended to constitute legal advice. This blog is provided solely for educational reasons, as well as to provide general information and a general grasp of the law, and is not intended to provide legal advice. By accessing this blog, you acknowledge that there is no attorney-client relationship between you and the blog publisher. The blog is not intended to replace professional legal advice from a certified lawyer in your country. If your disability claim has been refused and you require legal counsel, call a disability law specialist.