How will I know if my Long Term Disability Policy contains a limited pay period for physical or mental disabilities and is there any way to get around these limitations?

Self reported symptoms limitation

It is common practice for disability insurance companies to find ways to limit the amout of money they have to pay to claimaints. One of the ways they attempt to limit their exposure is to add limitations into their policies that require the claimant to provide “objective evidence” to prove they have certain conditions such as fibromyalgia or chronic fatigue syndrome. The glitch is that it is impossible to provide “objective evidence” for these conditions since these tests do not exist. Recently, courts have ruled that insurance companies cannot require such objective evidence for these conditions as this is an unfair requirement as it is impossilbe to provide.

Mental nervous limitation in disability policy

It is pretty well known in the disability insurance arena that group disability plans commonly contain a 24 month limitation for mental nervous conditions. If a policy holder makes a claim for benefits as a result of depression, anxiety, post tramatic stress disorder or any other mental nervous conditon, the policy holder is limited to 24 months of benefits.

Limitation for any neurological or muscoskeletal or soft tissue claim

In addition to the mental nervous limitaiton, several insurance companies are also adding limitations for physical conditions such as injuries or disorders of the spinal cord, extremities and other soft-tissue disorders. If a claimaint has a spinal cord inury which prevents him or her from being able to sit, stand or walk for prolonged periods of time as well as lift bend or stoop, and as a result are permanaenly disabled and unable to perform the material and substantial duties of their occupation, he or she may only be able to collect disability benefits for 24 months. This is devastating to many policy holders since physically they are unable to work, their treating physicans support their inability to work, but regardless of all the medical support, their policy only allow benefits to be paid for a maximum of 24 months.

What does this limiting language look like?

An example of some limiting language that may be contained in your long-term diability policy is as follws:

For Disability Due to Mental or Nervous Disorders or Diseases, Neuromusculoskeletal and Soft Tissue Disorder, Chronic Fatigue Syndrome and related conditions.

If You are Disabled due to one or more of the following, We will limit Your Disability Benefits to a per occurrence maximul equal to the lesser of:

  • 24 months; or
  • The Maximum Benefit Period

2. Neuromusculoskeletal and soft tissue disorder including, but not limited to, any disease or disorder of the spine or extremities and their surrounding soft tissue; including sprains and strains of joints and adjacent muscles, unless the Disability has objective evidence of:

  • Seropositive Arthritis;
  • Spinal Tumors, malignancy, or Vascular Malformations;
  • Radiculopathies;
  • Myelopathiesl
  • Traumatic Spinal Cord Necrosis; or
  • Myopathies; or

3. Chronic fatigue syndrome and related conditions.

There are some exceptions to the above limitations; however, unless the claimant can provide “objective evidence” of the exceptions, the insurance company will not extend benefits beyond 24 months. Even if a claimant undergoes an MRI that reveals herniations or bulging discs that require spinal surgery, the policy will still limit benefits to 24 months. The only way to exceed the 24 month limitation is to provide objective evidence of either Seropositive Arthritis; Spinal Tumors, malignancy, Vascular Malformations; Radiculopathies; Myelopathies; Traumatic Spinal Cord Necrosis; or Myopathies. These exceptions can be defined as follows:

  • Seropositive Arthritis: An inflammatory disease of the joints supported by clinical findings of arthritis plus positive serological tests for connective tissue disease.
  • Spinal: Components of the bony spine or spinal cord.
  • Tumors: Abnormal growths which may be malignant or benign.
  • Vascular Malformations: Abnormal development of blood vessels.
  • Radiculopathies: Disease of the peripheral nerve roots supported by objective clinical findings of nerve pathology.
  • Myelopathies: Disease of the spinal cord supported by objective clinical findings of spinal cord pathology.
  • Traumatic Spinal Cord Necrosis: Injury or disease of the spinal cord resulting from traumatic injury with resultant paralysis.
  • Myopathies: means disease of the skeletal muscle supported by clinical, histological, biochemical and/or electrodiagnostic findings.

3. Chronic fatigue syndrome and related conditions.

In no event will Monthly Benefits be payable longer than the Maximum

How Can I Help Ensure That My Claim Extends Beyond 24 Months?

It is imperative to make sure that your treating physicians are aware of the limitations in your policy so they can order the appropriate tests to determine whether one of the many exceptions applies to you. A claimant may fall under one of these exceptions, but if their physician fails to order to appropriate tests the record will lack objective proof and their benefits will be terminated after 24 months. Timing is also very important, since the claimant may test positive for one or more of the above exceptions after the administrative record is closed and as a result will not be permitted to add these result to the record. This can be devastating to their claim as a judge will not be permitted to consider any new information.

Further reading: Are There Exceptions to the Mental Illness Limitation in a Disability Insurance Policy?

Our disability attorneys have helped hundreds of clients to present claims that would not be limited by the 24 month limitation. Contact us for a free consultation to discuss your claim.


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Disability Company Reviews
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Showing 8 of 627 Reviews
Sun Life

What a mess

Reviewed by Unknown on September 12th 2023   Verified Policyholder | July 2020 date of disability
This place has no idea what day it even is. First they attach my claim to my previous claim in which was a new claim. They messed up and denied me then made me wait yet ag... read more >
Reply
Sent on September 12th 2023 by Attorney Gregory Dell

I am sorry to hear what you are experiencing. Make sure you deal with Sunlife writing and follow up every day. If you would like assistance please contact us.

Sedgwick

I was disabled 2003 by SS. I got SSDI 7 years too late.

Reviewed by Bunny on August 9th 2023   Verified Policyholder
I believe if Sedgwick would have moved on my Claim. They absolutely did everything not to answer my calls, change dates. I had already been through WV comp. Ins. Sold out,... read more >
MetLife

Only care about $$$$$

Reviewed by Allen Cox on August 8th 2023   Verified Policyholder | September 2013 date of disability
PLAY THEIR GAME FIGHT FIRE WITH FIRE.....after getting a copy of the insurance policy from my HR. I nipped a lot of the headaches quickly by calling their bluff word for w... read more >
Reply
Sent on August 8th 2023 by Attorney Gregory Dell

Allen,
Sorry to hear what you have been through. I am glad you fought back.

Sedgwick

They falsify documents and avoid contact as much as possible.

Reviewed by Jeff Allsop on July 27th 2023   Verified Policyholder | February 2023 date of disability
They avoided sending the documents needed for the claim for two weeks. I had to escalate with a call from my company's HR and Sedgwick (the only way I was ever able to get... read more >
Hartford

This company is a scam!

Reviewed by Hana K. on July 13th 2023   Verified Policyholder | December 2022 date of disability
The Hartford does not pay claims. The Hartford only collects premiums. The Hartford doesn’t care if you are terminally ill. I’ve been employed at my employer since 201... read more >
Prudential

California State Disabilty "OFFSET" never mentioned or outlined when enrolling for STD coverage.

Reviewed by MartyG on June 29th 2023   Verified Policyholder | May 2023 date of disability
All terms and conditions of receiving a claim benefit not made available when enrolling. Hidden elements of eligibility... not fully transparent with issues that might eff... read more >
Sedgwick

Not getting paid

Reviewed by Cezes on June 15th 2023   Verified Policyholder | March 2020 date of disability
I been battling Sedgwick about my claim. I was to get paid today and I did not get paid.Sledges is the worse company I ever had to deal with. I been fighting with my b... read more >
Sedgwick

Sedgewich is the worst-immediate denial of all requests for treatment. Rubber stamps DENIED ALL RFA’s

Reviewed by J on May 31st 2023   Verified Policyholder | August 2023 date of disability
Sedgewich immediately denies all RFA. They’re ur team are THEMSELVES not a independent medical team…
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Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

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No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via phone, email, fax, GoToMeeting sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

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