Long-term disability insurance (LTD) covers a portion of an individual’s former income if he or she becomes disabled before reaching retirement age. The precise conditions that qualify for LTD will depend on the details of the individual policy. LTD eligibility criteria medical evidence requirements, in particular, can vary widely from one plan to the next. Qualifying for long-term disability benefits can often be a challenging process, but understanding some of the common criteria private LTD insurers often look for and establishing a sense of the generally applicable expectations may make preparing to file your long-term disability claim less overwhelming.
LTD Eligibility Criteria: Medical Diagnoses and Assessments
One of the first questions people ask when they make the often difficult decision to file for long-term disability benefits is whether their condition will automatically qualify, and how they can meet the LTD eligibility criteria medical requirements if a simple diagnosis is not sufficient. The short answer is that the conditions that qualify for LTD under private insurance plans will always depend on the terms of the specific policy that applies.
The somewhat longer answer is that the terms of your specific LTD policy will still determine both what conditions (if any) are considered presumptively qualifying and the options you have for proving disability if your diagnosis is not on that list. However, there are some general trends that are common in the private insurance industry. Becoming familiar with these common trends and the types of policies to which they are most likely to apply can help you to find a firmer footing as you prepare your LTD eligibility criteria, medical documentation, and other requirements.
Federal Programs and Definitions of Disability
One federal law, and two federal benefits programs, are in sufficiently wide use for their definitions of disability, and the criteria they use for assessing eligibility for benefits, to make useful points of reference. These are:
- The Americans with Disabilities Act (ADA), adopted in 1990 and amended in 2008 to clarify the criteria that should be applied in determining whether an individual qualified for protected status under federal law
- The disability benefits provided to some veterans with service-related disabilities through the Department of Veterans Affairs (VA)
- The SSDI program, overseen by the Social Security Administration (SSA)
Of these three, it is important to note that the ADA does not direct the distribution of any benefits; rather, it mandates certain accommodations for people with disabilities in schools, workplaces, and most public spaces. In employment contexts, ADA compliance typically falls under the jurisdiction of the Equal Employment Opportunity Commission (EEOC).
ADA Disability Criteria
An individual is considered to be disabled under the ADA if he or she has an impairment, whether mental or physical, that “substantially limits” at least one “major life [activity]” by comparison to the experience of “most people in the general population.” Notably, nothing in the ADA text implies an inability to work. Rather, ADA criteria that apply to places of employment are to a great extent aimed at ensuring that individuals who do deal with “substantial” limitations on one or more of their daily activities are not kept from earning a living solely by the lack of readily achievable accommodations. One implication of the ADA is that, if you are or believe you would be able to return to work with accommodations from your employer that would not prevent you from fulfilling the responsibilities inherent in your position, then qualifying for long-term disability benefits may not be likely. However, in the event your employer refuses to work with you to make those accommodations, you might instead be able to seek compliance assistance through the EEOC.
Social Security Disability
The SSA does not consider an individual to be “disabled” unless he or she is unable to engage in what the agency calls “substantial gainful activity” (SGA), defined as work for pay that exceeds a monthly threshold. The monthly threshold is adjusted on an annual basis to keep pace with the cost of living. However, there are cases where individuals are attempting to coordinate their long-term disability benefits with Social Security disability because the SSDI definition of disability is so restrictive. In these cases, some diagnoses that are considered presumptively disabling by the SSA will often meet the standards for qualifying for long-term disability benefits under a private LTD policy.
VA Disability Criteria
Instead of defining disability as an impairment that imposes “substantial” limitations on an individual’s day-to-day activities, the VA uses a “disability ratings” system. Under the VA guidelines, individuals with service-related disabilities are classified according to the total degree of disability resulting from their conditions.
The amount of VA disability benefits for which a former service member is eligible is inversely proportionate to his or her percentage rating, with the least-disabled category (19-29% disabled) receiving the least benefits and the most-disabled category (90-94% disabled) receiving the most. If an individual has more than one partially disabling condition, then the percentages are added together to get a combined disability rating. One way of thinking about the VA disability requirements in relation to filing your claim under a private long-term disability insurance policy is that conditions that would receive a high disability rating in the VA system are more likely to be conditions that qualify for LTD than are those that fall lower on the VA scale.
Common LTD Eligibility Criteria: Medical Conditions and Policy Types
Short-term disability insurance (STD) may cover any condition that keeps you from performing your ordinary job responsibilities for longer than the period normally allowed by sick leave. It is important to remember that the percentage of income replaced and the duration of even short-term coverage can vary from one plan to another. Long-term disability insurance, on the other hand, typically does not begin paying until short-term disability insurance has run its course. Depending on the type of policy you have, STD may cover any condition that prevents you from doing the job you were in before you became disabled, or may only offer coverage if your condition prevents you from working in any role.
Own Occupation LTD
Policies that replace a portion of your income if you are unable to return to your former position are called own occupation disability insurance. Generally speaking, you need to evaluate whether there are reasonable accommodations you could request from your employer under the ADA that might allow you to fulfill the basic responsibilities of your position, or a similar role if your former job is no longer available after you complete your STD.
Any Occupation LTD
Policies that replace a portion of your income only if you are unable to return to work regardless of the job requirements are known as any occupation LTD. These policies have overall guidelines that are similar to SSDI eligibility criteria. They are typically for individuals who are unable to work, and for whom there are no reasonable accommodations a workplace could make that would enable the individual to effectively fulfill the demands of full-time employment. However, the conditions that qualify for LTD may not always be the same as those listed by the SSA, so it is important to familiarize yourself with the terms of your specific policy.
Conditions That Qualify for Long-Term Disability
Even with differences from one policy to another, and substantial differences by policy type, there are some broad commonalities in eligibility criteria for long-term disability, and some conditions that are often recognized as carrying a high likelihood of disability. Some examples include:
- Amyotrophic lateral sclerosis (ALS)
- Parkinson’s disease
- Traumatic brain injury (TBI)
- Lupus
- Stroke (or the symptoms of damage caused by a stroke)
A great many conditions may qualify for LTD based on the severity of their symptoms in a particular patient. A number of potentially severe mental health conditions fall into this category, such as bipolar disorder and schizophrenia (both listed as possible qualifying conditions under SSDI rules).
Symptom severity can be especially significant in conditions that are generally recognized as “progressive” but that do not develop at a uniform pace across all patients. ALS, multiple sclerosis and Parkinson’s disease are all progressive conditions. If you are given a diagnosis of a progressive condition, you may be able to help yourself prepare for the future by taking proactive steps to become familiar with the LTD eligibility criteria, medical documentation requirements, and other guidelines set out in your individual policy.
Tips for Preparing to File a Long-Term Disability Claim
Qualifying for long-term disability benefits can unfortunately be a challenging, and in many cases confusing, process. Familiarizing yourself with conditions that qualify for LTD under many plans is often a useful step, but the terms that will be binding are those outlined in your individual LTD policy. Similarly, the medical evaluations required of SSDI applicants may be a useful tool for reference. Remember that the LTD eligibility criteria medical assessments that apply in your case will be based on those established in your policy documents. If your long-term disability insurance is through your employer, you may also want to check the ERISA (Employee Retirement Income Safety Act) claims processing requirements for employer-sponsored LTD plans, and if your state has strict insurance regulations, reviewing those may prove helpful as well. Take notes as you learn, and reach out to your support network or consult with a trusted attorney if needed.
