It’s extremely common to develop a health issue that makes it difficult or impossible to work. You might face pain, illness, or chronic health conditions due to age, work duties, environment, or simple chance. As a result, some employers offer short-term and long-term disability insurance, which provides payment if a disability prevents you from working.
Employees with a long-term disability policy may be eligible for insurance payouts if they can no longer work. Explore the most common reasons people file long-term disability claims, who is eligible for a claim, and how a long-term disability attorney can help you.
The Most Common Causes of Long-Term Disability Claims
It isn’t possible to pinpoint specific diseases that lead to long-term disability claims, as this information is typically protected. However, when filing a claim, most people must submit medical information that includes their diagnosis.
Medical professionals typically diagnose conditions using codes in the International Classifications of Diseases, or the ICD. The Integrated Benefits Institute (IBI) can research disability claims using these codes. They collect how many claims were filed under a category of codes and then use that data to determine what types of disabilities often led to short-term and long-term disability claims.
According to the IBI, most long-term disability claims in 2020 were for conditions in one of the following four categories:
Muscle and Joint Conditions
The vast majority of long-term disability claims in 2020 were for musculoskeletal system conditions: nearly 27% of claims were for conditions related to the muscles, connective tissues, or joints. This category includes conditions like arthritis, osteoporosis, and swelling or lesions in the joints.
About 14% of long-term disability claims in 2020 were for neoplasms or tumors. For research purposes, the IBI only counted claims for cancerous tumors or melanomas for research purposes and excluded benign tumors.
Nervous System Disorders
Nervous system disorders are a fairly broad category, including conditions like migraines, nerve-related back pain, sleep disorders, and other chronic conditions linked to nerve problems. However, they were the third most common diagnosis, leading to long-term disability claims.
The fourth most common category leading to long-term disability claims were conditions affecting the circulatory system. This includes heart disease and diseases of the arteries or capillaries.
Long-Term Disability and the Law: What to Know
If you receive disability insurance benefits through your job, these benefits are protected under federal law. The Employee Retirement Income Security Act (ERISA) outlines several requirements for employees and insurance companies.
Your workplace must provide a copy of your Summary Plan Description, which explains what your plan covers, who is covered, requirements for filing claims, and any deadlines or time limits for filing and appealing claims. If you didn’t receive your plan information, check with your employer.
Under ERISA, you have limited time to submit a claim. Specific deadlines vary per policy. The law also requires that your insurance company review your claim within 45 days and notify you if it will take longer to do so.
Am I Eligible for Long-Term Disability?
Your eligibility for long-term disability depends on what your insurance policy covers. While your Summary Plan Description should detail eligibility requirements, most policies determine eligibility based on factors like:
How long you work: Most long-term disability policies only cover full-time workers, although some also cover part-time employees.
The extent of your disability: Disabilities that prevent you from working will usually be compensated at a higher rate. If you can’t work at the same capacity that you used to but can still work, your eligibility may change.
Whether you are still employed: Some insurance companies will not pay benefits to an employee still employed with the company, even if you can no longer work in your previous role.
What conditions you have: Every policy covers different conditions. Whether or not a condition is covered also depends on its cause. For example, insurance companies may not cover liver disease linked to alcohol use.
Preexisting conditions: Developing another condition before filing for long-term disability may affect your eligibility.
Prerequisites for an insurance claim: Some policies require that you complete certain procedures to file a claim. For example, your insurance company may require that you file for Social Security Disability Insurance (SSDI) before you can receive long-term disability benefits.
Every plan varies, and some have stricter requirements than others. If you’re unsure about your eligibility, consult a long-term disability attorney.
What Do I Need to File a Claim?
Every insurance policy has different requirements for filing a long-term disability claim: check your Summary Plan Description to find information on your specific policy. Generally, however, you will need medical evidence of your condition, proof that it prevents you from working, and that the condition has kept you from working or is expected to keep you from working for six months or longer.
Seeking medical documentation from your healthcare provider is an often-necessary first step. Depending on your condition, you may also need documentation from a relevant specialist explaining how your condition affects your ability to work.
What Can I Do if My Claim Was Denied?
When a disability prevents you from working, receiving a denial from your insurance company is a painful experience. Under ERISA, it’s mandatory for your insurance company to tell you why your claim was denied and offer you the ability to appeal the decision.
Before you appeal your decision, it’s a good idea to seek out a law firm familiar with long-term disability cases. The laws around long-term disability claims are complex, and you have a limited number of appeals. Getting legal advice from a skilled attorney reduces the risk of your appeal being denied.
Attorneys are familiar with the requirements for long-term disability and how the appeals process works. They can determine what you need to successfully appeal, help you file the paperwork necessary for your claim, and represent you in any subsequent legal proceedings. A lawyer can also recognize and fight a wrongfully denied claim.
Contact a Long-Term Disability Lawyer in Illinois, Florida, Texas, or Colorado
Nessler & Associates is prepared to help anyone who needs help with their long-term disability claim in Illinois, Florida, Texas, or Colorado. The attorneys at our law offices can help you review your insurance policy, build a strong claim for long-term disability, and appeal any unjust denials. Call us at (800) 727-8010 or fill out our online form to schedule a free consultation.