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:

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.

Comments (2)

  • A [barely functional] Gimp,

    Your employer is responsible for maintaining a copy of any and all disability policies you’re covered under so you can request a copy from them. As to questions 2 and 4 there is no hard fast answer, as each case is fact specific. As for SSD and LTD, normally your LTD benefit will be reduced by the amount received from SSDI. However, I would refer you to your policy when you receive it to confirm. Please feel free to contact our office to discuss how we may be able to assist you in filing for disability.

    Stephen Jessup Nov 6, 2013  #2

  • 1. How do I even find out what my company sponsored LTD policy is or covers? The company is Liberty Mutual.

    [Background] I have the 70% of base + 70% of full salary (up to a max of 5K per month). I have a number of health issues (ostheo-arthritis in hands, knees, hips, shoulders and spine, compression of the nerve root at L4/L5-S1, hypertension and some sort of vascular insufficient in my legs/occasionally arms that is currently under investigation).

    I’m trying to figure out where to go from now. I am 57 3/4 years old. It is highly possible that my doctor is going to say that I need to elevate my legs 4-5 hours per day OR risk losing a leg (it is very serious. I have a prior condition of DVT through administration of Plavix prior to the discovery of the genetic marker, which I have, prohibiting its use). I’m already in a wheelchair (11 years because of the OA).

    2. What sort of tests should my doctor be doing NOW with an eye to filing LTD?

    3. If I get SSD and LTD – is one counted against the other? (particularly if I get SSD of $2200, how does that affect an expected $4725 in LTD?)

    4. How long should I expect the LTD insurance process to take?

    A person’s first SSD check can take from 6 months (the minimum amount of time you have to wait for a paycheck) up to 2 or even 3 years. Medicare doesn’t start for 24 months (from date of initial claim).

    A [barely functional] Gimp Nov 5, 2013  #1

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