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ERISA Long Term Disability Claims Process

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Your Long Term Disability claim can take many different paths, depending on a number of factors. However, the overall general course is similar.

Is your LTD plan covered under ERISA, or State Law?

First, you need to determine if your case is covered under state law or ERISA. If it is provided by your employer, it is generally covered by ERISA, the big federal law, which mandates certain rules and procedures.

If you bought the plan directly from an insurance salesman, then it is likely covered by state law.

There are advantages and disadvantages to both. Even though ERISA was intended to protect employees and their benefits, it is commonly accepted that ERISA protects insurers to the disadvantage of employees.

One such example is ERISA allowed insurers wide discretion to deny long term disability claims applications. As long as they didn’t abuse this discretion, you lose.

Well, some states took action, such as California which enacted a rule forbidding insurers from reserving discretion for themselves. The standard for determining a claim must be objective. This helped level the playing field a little.

Most LTD plans are covered by ERISA, but not all. We will cover ERISA LTD plans here, since those plans covered by state law don’t require specific procedures as laid out by ERISA.

Before Filing an LTD claim under ERISA

So, you are disabled, and need to file a claim. Your LTD plan was provided as a benefit from your employer. The first thing you need to do is review information from your plan.

Reviewing LTD Plan Documents

There are generally 4 documents to review:

  1. Summary Plan Description (SPD). This is a brochure that is a summary of the disability plan. It is a detailed summary, how it works, benefits it provides, and how to file claims for benefits. It should describe your rights and responsibilities under ERISA and your plan.
  2. Summary of Benefits and Coverage (SBC). This is a short easy to understand, 30,000 feet overview of your plan. Not always provided, and not very useful, but it is worth looking over.
  3. Plan Document. This is it. This is the actual plan. SPD’s mentioned in #1 are useful, but the actual plan document is what controls. This is a very long document however, and an ERISA LTD attorney would likely be needed to review this.
  4. Claims Procedure Booklet. Also not always available, but the plan might have a separate pamphlet detailing the exact steps to filing a claim.

You can request these from the plan administrator. They are required to provide this to you. Make a written request to the plan administrator. You may need to contact your human resources department to get the plan administrators information.

Reviewing Your LTD Plan Requirements

Before applying for disability benefits, review the plan documents above to make sure you meet the requirements under the plan to qualify for benefits. You also need to understand the procedures for filing the claim.

Be aware of what your plan requires to file a claim. The SPD or claims procedure booklet must including information on where to file, what to file, and whom to contact if you have questions about your plan. Plans generally cannot charge any filing fees or costs for filing claims and appeals.

Request Your Medical Records

Before you file a claim for disability benefits, request and review your  medical records. Contact all of your doctors and request your complete medical chart.

IMPORTANT: Don’t forget to ask each medical provider whether they communicated with any insurance companies. If they did, you must get a copy of those communications as well.

If there are small errors (or big ones) in your record, write a letter to your doctor requesting they correct them. This is important because your case hinges on the medical records. If you feel resistance from your doctor about your disability claim, go to a new doctor. You need to stack the medical evidence in your favor from the very beginning.

Filing Your Long Term Disability Claim

Once you know the requirements for disability under your plan, the required procedures to filing the claim, and have reviewed and corrected any errors in your medical records, it’s time to file your claim. Your plan administrator should have sent you a claims packet, with a bunch of forms in them.

Some forms may include:

  • Employee Request for Information (the initial claim form)
  • Capabilities and Limitations Worksheet
  • Attending Physician Statement (filled out by your doctor)
  • Other Income Questionnaire
  • Authorization to Obtain Medical Information
  • Authorization to Obtain Other Information
  • Social Security Administration Authorization
  • Reimbursement Agreement
  • Work History and Education Questionnaire

And many other forms. They don’t make this easy on you. Be careful filling these forms out, because you are not required to return all of them. For example, by initiating the claim, your LTD plan is allowed to request all of your medical records. But LTD plans will try and get all of your information, even financial, tax, and personal such as credit reports. So if the packet includes an Authorization to Obtain Other Information, do not complete that.

IMPORTANT:Some insurers are extra sneaky and include both authorizations (medical and other) into one. You must not sign that, and instead, strike out the parts that are irrelevant.

Once you have all the forms filled out, go ahead and send the application for benefits in, and wait for a response. They are required to respond within a certain amount of days.

Do Not Resign Before Filing An Application

This is important. Many workers will resign and then file an application for disability benefits. The plan will deny benefits almost every time, arguing the LTD benefit expired upon your resignation from the company.

File When Your Salary Is The Highest, And Duties The Most Strenous

Your application will be most effective, and more successful, if you apply when your salary is the highest, and your duties the most strenuous.

Most plans pay a benefit as a percentage of your current salary. So let’s say the plan pays 60% of your current salary. The higher your salary at the time, the more you will get. Pretty self-explanatory.

If your work duties are quite strenuous, it is easier to argue you are disabled and can’t continue, then if the employer transferred you to a sedentary desk job answering phones.

So you should apply for benefits as soon as you have enough medical evidence proving your disability, but before transferring to a light duty job.

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