Submitting a long-term disability claim that will be approved by your insurance company is a complex process requiring attention to detail and a thorough understanding of insurance company tactics to limit their liability. Since 2000, I have worked with the team members at Schwartz, Conroy & Hack and have represented doctors, lawyers, business owners and others in successfully submitting long-term disability claims to a wide range of insurance companies. Those companies include Principal, Unum, Provident, Paul Revere, Guardian, Northwestern Mutual, Equitable, Standard, Met Life, NY Life, Mass Mutual, Hartford Group, Great West, Trustmark, Lincoln Life, Cigna, Ameritas and others. Many of these clients are referred by former clients, who tell them if I take their case, there's a very high likelihood that their claim will be fully approved.

Examine the Policy 

My first step is to carefully comb through the client's policy or policies, which may be individual and/or group plans. I look at what the maximum benefit is, and whether benefits are payable over their lifetime or for a finite period, such as until age 65. For some policies, the benefits period may vary depending on the type of disability. I also look at what the policy's “own occupation” time period is. For instance, many group policies have a 24-month “own occupation” period, which means benefits will be paid for the first 24 months if policyholders are unable to perform their regular occupation. Effective with the 25th month, the policyholder must be unable to perform the duties of any occupation in order to continue receiving benefits. 

Total Disability Claim vs. Partial/Residual Disability Claim

Clients who are no longer able to work in their occupation because of a disabling condition may look to file a total disability claim. Those clients who are continuing to work but have experienced a loss of income due to limitations caused by their disability may seek a partial or residual disability claim.

For a total disability claim, we discuss the date the client would like to go out on total disability. We also discuss in detail the client's occupational duties and medical conditions, and how these conditions prevent them from performing the important/major and material/principal duties of their regular occupation. I listen to these limitations from the client's perspective, but I also need to verify them with a qualified medical professional(s). I ask clients which doctor(s) will support their claim by providing a narrative along with other evidence. For a claim to be approved, it must have strong medical support.

Partial/Residual Disability Claim

Claims for residual or partial disability benefits are more complicated in that we must pick a date for onset of the disability, which involves tying three factors together: medical, occupational and financial. Clients may have a disabling condition that restricts them from performing some but not all of the duties of their occupation. For instance, a physician may have been doing procedures and office visits prior to the disability, but is now only able to do office visits. Or they may be able to do everything they did before, but it may take them more time. For instance, a surgeon may be able to perform fewer surgeries in a day. Either way, we examine their past tax returns and other financial data to determine when there was a drop-off in income and how much it was. We also examine the details of their occupation and their disabling condition, and how the disability has specifically impacted their ability to perform their work. As with a total disability claim, these findings need to be supported by a narrative letter and records from a doctor. 

Filing Notice of Claim and Request for Narrative

Once we determine the client has a viable claim and a doctor will provide support, we give the insurance company notice of claim and of our representation of the client, and we request claim forms. At this time, we also send a narrative request letter to the client's treating doctor(s) that provides the client's occupational duties, date of disability, the policy's definition of disability (which varies based on whether total or partial) and ask the doctor(s) to complete the attending physician statement and provide us with a narrative report setting forth their medical opinion, based on their care and treatment of the client, of how the client's disabling conditions, restrictions and limitations have rendered and, continue to render them, disabled as defined in their policy.

File the Claim

Once we have all the materials, we finalize the claim and submit it to the carrier in a timely fashion. After receiving the claim, the insurance carrier may require the client to sit for a field interview to go over the details of the claim. We accompany our clients to these interviews to ensure they assert their rights and receive the full benefits to which they are entitled. 

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.