A doctor’s importance of long-term disability insurance (LTD) claims lies in the unique position physicians and other healthcare professionals occupy with respect to providing the medical support crucial for LTD approval. Because approval of a long-term disability claim will typically be based primarily on medical evidence and its interpretation, healthcare professionals’ role in LTD claims is often to provide the benefit of their expertise in elucidating how and why an individual’s condition precludes re-entering the workforce. Understanding the types of evidence that may be requested, and where challenges are likely to arise, may help you to navigate your long-term disability claim with greater confidence.
Proving Disability for Private LTD Policies
Private long-term disability insurance plans determine disability according to criteria set out in each policy. These criteria can vary widely from one insurance company to another, and even between two plans offered by the same insurer. Generally, however, private LTD plans can be divided into “own occupation” vs. “any occupation” plans:
- Own occupation: The policy provides benefits if the policyholder is unable to continue working in the job position he or she had prior to becoming disabled (usually the position the person held at the time of enrolling in the policy).
- Any occupation: The policy pays out benefits only if the policyholder is unable to return to work, or continue working, in any position (i.e., transitioning to a job with a less demanding schedule or fewer physical requirements is not an option.)
A very common arrangement is for policies to offer an initial period of own-occupation coverage that is intended to help cover the individual’s loss of income until he or she can prepare for a change of occupation to accommodate his or her newly disabled condition. This provision is likely to apply in cases where the Equal Employment Opportunity Commission (EEOC) would consider an individual to meet the criteria for disabled under the Americans with Disabilities Act (ADA) or be considered to have a degree of disability under the rules applied by the United States Department of Veterans Affairs (VA). However, these cases would not meet the stricter requirements used by the Social Security Administration (SSA) to determine eligibility for Social Security Disability Insurance (SSDI). On the other hand, individuals who do meet those strict SSDI requirements are in many cases also eligible for coverage under private long-term disability insurance, even if their specific policy only covers any-occupation disability.
Types of Medical Evidence in Long-Term Disability Claims
To make any determination of disability, it is usually necessary to collect medical evidence. For long-term disability insurance, the medical evidence will typically need to show that the formerly employed individual is unable to return to his or her former position (own occupation disability), and possibly that he or she is unable to return to work in any position (any occupation disability). The exact criteria can differ depending on the rules of each disability program, particularly among private LTD plans, and so the type of evidence and extent of documentation a specific insurance provider and policy may require can differ as well. However, some of the most common types of evidence requested in private LTD claims are:
- Statements by the physician or other healthcare providers treating the individual.
- Results of diagnostic tests ordered by any of these professionals.
- An independent medical examination (IME), usually performed by a third party physician chosen by the insurance company.
Healthcare professionals play crucial roles in establishing evidence of disability and providing the critical record of medical documentation that is used to support long-term disability claims and appeal LTD claim denials. For the same reasons, the contributions of medical professionals can also be crucial in navigating the renewal process of long-term disability benefits that are typical for SSDI coverage and required by some LTD policies.
Attending Physician Statements
The attending physician statement (APS) is a document a healthcare professional who has been involved in your care prepares and submits to the insurance company or other disability services provider (e.g., SSDI) regarding information about your medical condition. If you have a complex condition and your care has involved consultations with multiple specialists, you may be asked to request an APS from each of them, so that they can speak independently to the aspects of your condition in which they have expertise.
If your care and treatment regimen have been coordinated by a primary care physician, then it can be helpful to start by speaking with this healthcare professional about your disability claims process. Ultimately, the goal here is usually to establish an accurate, holistic picture of your disability that takes into account your case history and the cumulative effect of all your symptoms.
Independent Medical Examinations
An independent medical examination (IME) is a common requirement for long-term disability claims. The “independent” qualifier means that the examination is carried out by a healthcare professional who has not been involved in treating the patient filing the LTD claim. Instead, the medical professional performing the examination will be an individual selected by the insurance company. The healthcare professional’s job in an IME is to perform an examination of the claimant and deliver an informed opinion on the individual’s capacity for work. These healthcare professionals are supposed to play a crucial role in ensuring fair handling of disability claims by providing unbiased assessments as “third parties” to the claims process. However, since the examining physician is chosen by the insurance company, individuals pursuing disability claims often question whether the results of their long-term disability medical examinations are truly impartial. Challenges to IME decisions are therefore frequently involved in the appeals process for LTD claims.
Diagnostic Test Results
One form of medical support crucial for LTD approval in many cases is the evidence provided by diagnostic test results. Unfortunately, by the time someone’s medical condition pushes him or her to file for disability, the person will have been through a number of diagnostic procedures aimed at identifying the individual’s condition, estimating the extent or progression of the injury or illness, and devising a treatment protocol to cure the patient or mitigate their symptoms. The diagnostic scans, exploratory surgeries, or other procedures performed to understand and address the patient’s condition typically create a documentary record showing the course of the individual’s debility. Often a crucial component of healthcare professionals’ role in LTD claims is to provide these records, frequently accompanied by their annotations highlighting key findings from each diagnostic performed.
Helping Your Own Case: How You Can Support the Crucial Role of Medical Professionals in Long-Term Disability Claims
For many people filing long-term disability claims, the documentation required can feel intrusive. The process itself may feel adversarial. The submission of additional documents can even feel like “adding insult to injury,” forcing the disabled individual to come to terms with the grief they will have experienced over the loss of their health and the life they had planned. Even though the review process for long-term disability claims can be deeply frustrating for a disabled policyholder struggling to prove a legitimate claim, there are a few steps you can take to support your healthcare professionals’ role in LTD claims as they provide the evidence needed to demonstrate the nature and extent of your disability.
Take Notes on Office Visits
Keep accurate records of all medical appointments. Include the dates and times of office visits. Mark the reason for each visit and make a note of whom you see. For “maintenance” visits, you may often be seeing a nurse or nurse practitioner. Try to make a note of each individual healthcare professional’s name, even if they are staff in a large office and you do not see them regularly. Document any concerns you or they raise, and any medical advice given, during the visit.
Keep Track of Diagnostics
Maintain a log of all diagnostic procedures, such as blood work, specialized scans, exploratory surgeries, and even vital signs checked during office visits. Make notes of all tests conducted, who ordered each one, what the results were, and how long it took for those results to reach you. Some diagnostics may be ordered in order to confirm or rule out a specific condition when the cause of one or more of your symptoms is not immediately clear. You may find it helpful to document the purpose of each diagnostic as a means of tracking conditions that have been ruled out, for which there is inconclusive evidence, or for which you have not yet been evaluated.
Correct and Record Any Errors
Make notes of any mistakes in your medical record, or any times when you have to correct information, such as a list of symptoms when a new symptom started (or stopped), during an appointment or check-in. Part of a doctor’s importance for long-term disability claims lies in their ability to accurately recount how your medical condition has unfolded. Ultimately, their job will be made harder, not easier, by a record with inaccuracies or inconsistencies. Correct any issues as soon as you notice them and as often as they occur, and mark the date when you addressed each discrepancy, in case it appears again.
Become Familiar With Your Patient Record and How To Request Copies
Be proactive in reviewing and compiling your own medical records. Often you may be able to access lab results and the notes from office visits in an online portal. Follow up on any inconsistencies, and make sure you are familiar with the costs and protocols for having additional copies sent to a third party (such as an attorney or long-term disability insurance provider) so that the process of collecting documents requires less background research on your part when records are needed.
Track Your Own Symptoms
Maintain a log, such as in a health tracker or symptom journal, documenting your own condition between medical visits. Bring your notes with you to any scheduled appointment with one of your healthcare providers so that you have them handy as a point of reference. You may also want to consider bringing a copy of the notes to leave with the doctor or other medical professional, to add to your file. Having this information at their fingertips can sometimes help physicians and other healthcare workers to refresh their memories to prepare their APS and otherwise provide the medical support crucial for LTD claims.
Take Care of Yourself
A doctor’s importance for long-term disability may loom large in your concerns, but it is important to take care of yourself as much as possible and make sure that you are familiar with the details of your LTD policy requirements, including the types of medical support crucial for LTD claims under the guidelines of your specific policy. Understanding healthcare professionals’ role in LTD claims governed by the terms of your policy can put you in a stronger position to help your doctors help you.
