Qualifying for disability insurance benefits is not a given just because you hold a disability policy through an employer or other organization. In this article, learn how to actually qualify for the disability insurance benefit in your existing policy.

The Dell & Schaefer disability insurance law firm handles long-term and short-term disability insurance claims rather than benefits provided by Social Security disability programs. There’s a big difference between the two, so this article focuses specifically on disability claims filed by insurance policyholders.

So, what does it take to receive disability insurance benefits and avoid a denied disability claim? That question is probably one of the most popular ones that comes up in a Google search, and for good reason. Disability policyholders are often unaware of what it takes to receive the assumed benefits.

Obviously, there must be some sort of sickness or injury that’s creating a limitation and preventing a policyholder from adequately performing his or her occupation. That’s the basic threshold. From there, in most cases, the disability insurance company will want to see support within the disabled claimant’s medical records. It’s important that the records line up with the doctor’s opinion that the person is unable to work or shouldn’t work, and that the person needs to take leave from his job.

Know Your Policy

Though Medical support is essential, the policy itself comes into play from the very beginning. When potential clients call an ERISA disability lawyer, it’s crucial to know what the specific policy provides and what they signed up for. At Dell & Schaefer, we’ve taken calls from people who have short-term disability coverage but never bothered to enroll in the long-term disability policies offered through their employers.

Be sure to obtain a copy of your disability policy prior to making a claim, which can be accomplished subtly by asking the HR department of your company for a copy of all your insurance policies, which can include health, life, dental, vision and disability. When you reach out to our law firm, we’ll provide you with a complimentary review of the disability policy and then discuss your options.

There are two critical things to look for in an employee-provided policy: the pre-existing condition clause and the length of time the person must have been employed before disability coverage begins.

“You may have all the medical (proof) in the world to support that you can’t work,” notes disability insurance attorney Stephen Jessup. “But if you don’t qualify beyond a pre-existing condition problem, you’re never going to see those benefits.”

Not all disability insurance policies are the same, even when it comes to pre-existing conditions. Almost every group disability plan includes a pre-existing condition period, but the length of time can vary. Some people even mistakenly believe that the Affordable Care Act (also known as Obamacare) wiped out pre-existing conditions across the board – but it only addresses the issue in health care, not in disability.

In general, the standard language in a group disability policy dictates that coverage begins after the worker has been covered for at least one year. Especially with long-term disability policies, the insurance company wants to avoid someone getting a job just to file for disability right away. However, these types of policies can also require a 90-day waiting period before a new employee is covered, which extends the amount of time you must wait after beginning a new job.

For example, the worker can have a pre-existing condition. If the policy says that you have to work a full 12 months before you file, and you stick it out and continue working in spite of an injury or a bad back, you still qualify for coverage.

Some disqualifying factors in a disability policy can include specified conditions such as mental, nervous, or neuromuscular skeletal limitations. The more you know about your policy, the more you’ll understand the terms and conditions that must be met before receiving benefits. The policy is the rule book, which gives you a roadmap to avoiding a disability claim denial and subsequent ERISA appeal or ERISA lawsuit.

The Importance of Medical Support

Medical support is the foundation of any claim. If you have a decent policy and no pre-existing issues, the insurance company will be looking at medical support as the evidence that validates your claim of disability. It’s not reasonable to expect an insurance company to just take your word for it; there must be evidence to back it up. Your medical history and health records are part of the “proof of loss” requirements in a disability policy.

When a claimant calls about qualifying for disability payments, I’ll always ask: Does your doctor support you? Many assume so, but it’s essential to actually have that conversation with your physician. The timing makes a difference as well. It won’t help much if the doctor’s support is built up after you’ve already stopped working.

The event that pushes you into a claim of disability should be the doctor’s examination, documentation of symptoms, and opinion that you should discontinue working. Ideally, the medical support will also indicate that you are unable to effectively perform your job or that the work is even potentially aggravating your condition.

One visit to the doctor is insufficient, especially with chronic pain such as a back that’s been bothering you for two years. The disability insurance company will come back and say that since you were able to work with this condition and didn’t seek medical treatment, it must not have been that bad. Unless it’s a catastrophic injury or an accident, you’ll need to build up your medical record over time.

The Attending Physician’s Statement

As part of a disability claim, the attending physician’s statement is a required form discussing the medical condition, your restrictions and limitations, and the reason that you are unable to work. Unfortunately, plenty of denials come when the doctors don’t want to get involved or fail to fill out the forms. They can also inadvertently check the wrong box, or even make notes in the chart stating that they’ve provided no restrictions or limitations on the claimant’s return to work.

That’s why it’s crucial to have these conversations with your doctor about what’s going on and ensure the medical record reflects the reality of your disability. Insurance companies are unlikely to send you for a physical review, so the existing medical records will be the basis of the decision. If there’s a limited amount of information available, the chance of success is going to be small.

You are only as disabled as you appear in your medical records. If you end up going to court one day, the federal judge isn’t going to see you. He or she is not going to hear any testimony about your claims or about your case or about how disabled you are. All the judge is going to do is review those medical records and a file claim or administrative record that’s produced by the insurance company.

How a Disability Insurance Attorney Can Help

If your claim doesn’t look strong on paper, how can a disability lawyer help? For starters, if you’ve failed to establish a credible medical record, a knowledgeable attorney can start building up your file. It may not happen the first go around, and you may get denied when the claim gets filed. It’s possible for the file to then get built up through an appeals process.

“We may have to go through sending that person through some sort of functional capacity testing or sending them through a vocational assessment of some sort to really break down the physical demands of their occupation or whatever the standard is at that point in time,” states disability insurance lawyer Cesar Gavidia. “In terms of helping them, you have to look at the complete picture and assess what’s going on and decide what it needs.”

There are really no hard, fast rules. Every case is going to be unique to the person, and the reality of a disability claim is that you may still never be approved. There’s a nuance and an art to the diagnosis translating into a disability. All the while, you are dealing with an insurance company that’s incentivized not to pay your claim.

However, when a claimant contacts us at Dell & Schaefer, we know the questions to ask in order to quickly get through all the potential issues and determine whether the person qualifies for disability insurance benefits. It can be a difficult process, but our job is to maximize the policy for the claimant.

If you need help anywhere in the country, feel free to call us at Dell Disability Lawyers for a free consultation. We welcome the opportunity to speak with you.