What Do I Need to Know About Short-Term and Long-Term Disability Insurance Claims?

Many employees are often unaware that they may be covered under a Short-Term Disability (STD) or Long Term Disability (LTD) insurance policy through their employer. If you are covered under an STD or LTD employer-sponsored group insurance plan, you have an additional shield of protection in the event a medical condition prevents you from performing the essential functions of your job. Here is what you need to know about filing STD and LTD claims.

STD Claims

STD claims are typically filed by employees who are unable to work for a temporary period of time due to illness or injury. These claims provide income replacement benefits for a limited period of time, typically ranging from a few weeks to several months, until the employee is able to return to work. The specific requirements for filing a short-term disability claim may vary depending on the insurance policy or employer-sponsored plan in question. Generally, the employee must provide documentation from a medical provider indicating that they are unable to work due to a covered illness or injury. The duration and amount of benefits provided through short-term disability claims also vary based on the plan or policy, as well as the employee’s salary and other factors. A typical STD policy provides for 6-12 months of benefits in the amount of 60%-66% of your salary.

LTD Claims

LTD claims are typically filed by employees when it is clear that they will not be able to return to work for the foreseeable future due to their medical conditions. LTD claims are often coordinated with STD claims so that when a claimant exhausts their STD maximum benefit period, they can then be considered for LTD benefits and receive continuing income replacement. If the LTD claim is not coordinated with the STD claim, you will have to wait until the LTD waiting period (typically 6 months) is exhausted before receiving a benefit payment.

The value of having LTD coverage is that you could continue to receive benefits until your Social Security Normal Retirement Age, provided that you continue to meet the definition of disability and other terms of the LTD policy.

However, it is important to note that LTD claims are often more scrutinized by disability insurance carriers than STD claims due to the long-term nature of the payout. There are many exclusions and limitations that the insurance carrier can impose in an LTD policy to prevent your LTD claim from continuing through retirement age.

Issues to look out for include:

• Meeting the Definition of Disability: LTD policies typically have a more stringent definition of disability than STD policies, which can make it more difficult for claimants to qualify for benefits. The policy may require the claimant to be unable to perform any job, rather than just their own job. Typically, the LTD policy will initially require the claimant to show that they medically cannot perform their own job, but will then impose the more stringent definition of disability once a claimant has received two years of benefits.
• Pre-Existing Condition Exclusions. LTD policies often have a pre-existing condition exclusion that can prevent the claimant from receiving benefits if their disability is related to a medical condition that existed before they enrolled in the policy. To circumvent this issue, it is typically best for an employee to work for their employer for at least one year prior to filing a claim for LTD benefits.
• Mental Illness and Subjective Symptoms Limitations. If you are claiming that you are disabled to work due to mental illness, chronic fatigue syndrome, chronic pain syndrome, or some other illness with “subjective symptoms,” many LTD policies will limit you to only receive two years of benefits. To prove that you are entitled to ongoing benefits you will have to show that there is a physical condition that, on its own, disables you.

Filing an Appeal

If your STD or LTD policy is governed by ERISA and your claim is initially denied, you will have 180 days to file your appeal. It is best practice to submit all of the medical evidence that you want the insurance carrier to consider all at once with your appeal. Therefore, it is our recommendation that you don’t file your appeal immediately. Rather, we recommend consulting with an experienced STD/LTD lawyer to assist you with putting together your appeal. In addition to crafting a legal argument for you, your lawyer may refer you to undergo an independent evaluation to best capture the extent of your impairment. Each case is different, however, so it is best to discuss the strengths and weaknesses of your case with a lawyer before proceeding with the appeal.

Overall, it is important for STD and LTD claimants to carefully review their policy, understand the requirements for filing a claim, and work with their healthcare provider and the insurance company to ensure a smooth and timely claim process. If you are interested in learning more about your eligibility for STD and LTD benefits, please give our office a call today at 703-558-9311 for a free consultation or fill out our online contact form by clicking here and we will contact you.