How to Prove Long-Term Disability in an ERISA Claim
Before an insurance adjuster approves your disability insurance claim, they will investigate and look for reasons to deny or limit your benefits. You need to anticipate this investigation, which is why a successful long-term or short-term disability application includes more than your completed forms. A strong LTD claim also contains detailed evidence that documents your medical conditions, identifies your limitations, and shows that you meet the policy’s definition of disability.
Building this evidentiary record isn’t a simple process. In this article, we explain how you can “stack the record” and prove to the insurance company or the courts that you’re eligible for disability benefits.
How Do ERISA Plans Define Disability?
Long-term and short-term disability insurance plans define “disability” in several ways.
- Own occupation: Your medical conditions or injuries prevent you from doing your current job
- Any occupation: You cannot do any work within the national economy due to your health issues
- Regular occupation: An illness, chronic condition, or injury limits your ability to perform your job, either as you actually did it or how it’s generally performed
Many short-term disability plans include an “own occupation” or “regular occupation” definition, while LTD plans tend to favor the “any occupation” standard.
At Bryant Legal Group, we always encourage people to review their long-term disability policy before they apply for disability insurance benefits. Your disability insurance plan’s Plan Document or Summary Plan Description (SPD) will identify which definition applies to your claim and outline the terms and conditions you must meet to qualify for benefits. If you need help interpreting your plan’s terms and conditions, you should schedule a consultation with an ERISA lawyer right away.
- Related Article: 5 FAQs About Private Disability Insurance Claims
What Types of Evidence Do I Need for a Disability Insurance Claim?
When you apply for short-term or long-term disability benefits, you’ll initially fill out a form that provides your medical conditions, your doctors’ and providers’ contact information, and information about why you cannot work. However, that is just the beginning of your long-term disability claim.
The disability insurance company will ask you to sign medical releases and fill out even more forms. They may even assure you that they’ll carefully investigate your disability claim, telling you to leave it to them. However, leaving it to them is never in your best interest.
Disability insurance companies and their adjusters don’t always do a thorough job of investigating claims. They may even issue a decision before they have all of your treating doctors’ records, relying instead on their own “consulting physicians” who never examined you. That’s why our disability attorneys build their own files and submit as much evidence as possible. Every disability insurance claim is unique, and you will need a lot of evidence that documents your symptoms, limitations, and work history.
Our lawyers typically collect the following records as part of an ERISA disability claim:
- Medical records outlining your doctors’ appointments, hospitalizations, and other visits
- Diagnostic studies such as MRIs, EKGs, EMGs, x-rays, and bloodwork
- Detailed statements from your medical providers about your medical conditions and ability to perform specific tasks
- Functional capacity evaluations (FCEs) and other assessments
- Resumé that outlines your training, education, and work experience
- Your current job description and other information from your employer
- Reports from medical and vocational experts
- Your statements about your symptoms, abilities, and health issues
While it’s important to collect as much helpful evidence as possible, you also need to understand that not all records and opinions are created equally.
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Strengthen Your Disability Claim With Objective Evidence
Generally speaking, you can break evidence into two different categories:
- Objective: Based on facts and measurable data, like when an MRI shows a herniated disc or a cardiac catheterization identifies a blocked artery
- Subjective: Information that can’t be measured by medical instruments or tests, such as your level of fatigue or pain
Insurance companies and judges overwhelmingly prefer objective evidence since it’s measurable.
While many diagnoses are linked to objective evidence, it’s not always possible. For example, there isn’t a test that objectively measures ringing in your ears that’s associated with tinnitus or chemotherapy-related fatigue. What do you do in these situations?
First, consistent medical care is essential. Your doctors’ notes should track the progression of your symptoms, and your medical team may even find objective evidence that explains your allegedly “subjective” complaints.
Second, make sure you provide honest and accurate information to your doctors. When your symptoms are mostly subjective, your credibility is very important. If you give your providers and the insurance company different stories about the severity of your issues, the adjuster may use these inconsistencies to deny your disability insurance claim.
When Can I Submit Evidence in an ERISA Claim?
ERISA (Employee Retirement Income Security Act of 1974) is a federal law that controls many employer-funded benefit plans, including long-term and short-term disability benefits. While the law aims to protect workers, it isn’t always easy to navigate. One of ERISA’s biggest problems involves when you can submit evidence.
There are three primary stages in an ERISA disability claim:
- Application phase
- Administrative appeal (insurance-level appeal)
- Federal court lawsuit
You can only provide evidence during the application and administrative appeal phases. In most cases, the federal court will not consider additional evidence, no matter how important, if the insurance company did not have access to it when it was considering your claim.
So, it’s critical to work with a lawyer early on in your long-term or short-term disability claim. Your legal team should help you identify all the necessary and missing information that you need to build your case. Lawyers sometimes call this process “stacking your record” since your goal is to provide as much evidence as possible that supports your disability claim.
RELATED: Disability Insurance in a Nutshell
Bryant Legal Group: Client-Focused Disability Insurance Lawyers in Illinois
At Bryant Legal Group, we meticulously investigate our clients’ claims, collecting their medical records and other information in support of their disability cases. If you have questions about your case and evidence, contact our Chicago office today.
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