How Does an Insurance Company Evaluate a Long-Term Disability Claim?

How Does an Insurance Company Evaluate a Long-Term Disability Claim?

An insurance company considers various sources of information about your medical condition to decide if you are eligible for long-term disability benefits. When you apply for these benefits, you will fill out a claimant statement, or a personal narrative describing your disabling medical conditions and how they affect your daily life. You also can specify how your medical conditions prevent you from doing the essential duties required for your job.

The insurance company also will consider a statement from your doctor, which typically sets forth your diagnoses, treatment plan, and long-term prognosis. This statement also may provide your limitations and give an opinion about your ability to work. In addition to the physician’s report, the insurance company will consider all your medical records from all treating doctors, hospitals, and other medical facilities. Therefore, individuals applying for long-term disability benefits should be sure that the insurance company receives all their medical records for full consideration of their claim. Their medical records accurately reflect the diagnosis of their medical conditions, symptoms, treatment, and prognosis.

Other evidence that insurance companies may consider in evaluating a long-term disability benefits claim include:

  • Employer statement providing information about your job duties, hours, and rate of pay
  • Evidence of having been approved for Social Security Disability benefits, including a Notice of Favorable Decision from the administrative law judge hearing the claim
  • Detailed job description if not provided by the employer
  • Letters from the claimant’s family member, caregivers, and coworkers about the effects of their medical conditions on their ability to complete daily activities and work duties
  • If the claimant’s statement form asks for only limited information, claimants also can write a letter describing their functional limitations and how their symptoms impede their ability to work.

The operative eligibility standard for many long-term disability benefits is whether you can perform the essential functions of your occupation. Over time, however, this definition may change to whether you can perform any occupation, based on your education, training, and experience. These are two very different standards, and the insurance company likely will evaluate your medical conditions under each criterion according to the policy terms.

Bonnici Law Group has handled the claims of countless individuals who have encountered difficulties in procuring long-term disability benefits under their employers’ ERISA-governed insurance policies. We will protect your rights and advocate on your behalf throughout every stage of the claims process. Call our office at 619-259-5199 to set up an appointment to speak with us today.

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