Both short-term and long-term disability claims are evaluated using a variety of factors to determine if an individual is eligible to receive benefits. It is not nearly as simple as having your doctor sign a statement that you are disabled and then the claim is approved, although short-term disability claim determinations are often based, at least initially, by the treating doctor’s completion of a certification form developed by the U.S. Department of Labor for employees to condition.
Key Steps in the Insurers’ Disability Claims Evaluation Process
1. Review of Policy Provisions
Evaluations of both short-term and long-term disability claims always begins with a review of the specific policy provisions related to the claimant’s disability and any exclusions or limitations that may be applicable. Such terms include consideration of the definition of disability, waiting periods before benefits comments, benefit amounts; i.e., a percentage of income or a fixed benefit amount, exclusions for pre-existing conditions or other exclusions that may relate to the cause of the claimed disability, and other relevant provisions.
Related Article: Why Do Disability Claims Get Denied?
2. Medical Documentation
In addition to certification of disability from the claimant’s treating doctor, the insurance company will usually require the claimant to submit additional medical documentation such as office visit notes, test results, and other relevant information related to the claimant’s diagnosis, treatment, and functional restrictions and limitations.
3. Review of Occupational Requirements
In deciding on whether to approve or deny a short-term or long-term disability claim, the insurance company will evaluate the physical and mental duties of the claimant’s occupation and compare such requirements to the medical information that has been collected in order to determine whether the medical findings impair the claimant’s ability to perform the duties and responsibilities of their occupation and a regular and consistent basis.
A diagnosis alone is never enough to establish disability unless the condition has resulted in an impairment of the claimant’s ability to perform the physical or mental duties of a particular occupation. An example is someone who has been newly diagnosed with Parkinson’s disease. The condition may ultimately progress and result in a disability but when initially diagnosed, the limitations would likely only have a minor, if any, impact on a claimant’s ability to work.
4. Other Issues That Go Into a Disability Assessment
All short-term and long-term disability benefit plans contain provisions that grant the insurance company the right to have the claimant examined by a doctor of its choosing. That does not mean the insurance company will obtain such examinations in every case, but in some situations, the insurance company is only able to get the information it needs to evaluate a claim by hiring a doctor to perform an evaluation. Such assessments will typically involve a physical examination, review of medical records, and other tests to determine the extent of the claimant’s disability and their ability to work.
Claimants should not automatically assume that examiner will be hostile and is hired to give the insurance company a basis to deny the claim. However, claimants should be wary and when attending an examinations requested by insurance companies, they should note any hostile behavior by the examiner and any variation or deviation from the type of exam their treating doctor typically performs.
The insurance company may also conduct video surveillance to determine whether claimants are engaged in activities they claim they are unable to perform. Surveillance is costly, though, and rarely yields results that serve as the basis for a claim denial. Surveillance may only be conducted in the open, and it is an invasion of the claimant’s privacy rights for an investigator to use a high-powered telephoto lens to peer into the claimant’s home. Nonetheless, if the claimant’s back yard is visible to others, it is not unlawful to videotape claimants performing activities such as gardening in their yards.
Social media has also become an important investigative tool for disability insurance companies. Claimants should therefore be careful about what they post or what their friends post about them to avoid an insurance company misconstruing the activities the claimant is actually performing.
There is a popular myth that there is rampant fraud in disability insurance claim. That myth is patently untrue since it would require a massive conspiracy to submit an illegitimate claim to a disability insurance company. Therefore, claimants should not assume that their claims will automatically be viewed with suspicion so long as their doctors have provided evidence confirming their disability.
5. Ongoing Monitoring
Once someone is approved to receive either short-term or long-term disability benefits, the insurance company will typically require ongoing monitoring to ensure that the claimant’s condition has not improved and that they remain eligible for benefits. Such monitoring involves collection of reports from the claimant and from the claimant’s treating doctors at periodic intervals so that the insurance company can determine whether the claimant is getting better, worse, or has achieved maximum medical improvement. For chronic conditions, the frequency of such reporting is reduced after a period of time when it becomes apparent the claimant’s condition is unlikely to improve.
Understanding the STD and LTD Claims Evaluation Process and How to Improve Your Chances of Success
Overall, the process of evaluating long-term disability claims can be complex and time-consuming, both for claimants and for insurance companies who need to ascertain whether a claim is valid. However, both claimants and insurance companies are working toward the same goal – that valid claims get paid. And most claims do get paid – promptly. It is important for claimants to carefully review their policy and to provide as much detailed medical documentation as possible to support their claim, especially test results such as x-rays, MRIs, blood tests, and other objective proof. Claims that are well-supported by objective proof of loss are likely to be approved more quickly and with less bother and hassle so that the claimant is able to focus on their health and not be distracted by ongoing requests from their insurance company.
