Most are familiar with the famous sketch of the simultaneous-silhouette of the older and younger woman appearing within the same image. Both women can be seen within the same drawing. Depending on the viewer’s perspective, the image appears to be of one of two different people. While viewing the image, the mind can move back and forth, alternating constantly between the two different people. The picture serves as an apt metaphor for claims involving the payment of long-term disability benefits.
Similarly, two reviews of the exact same set of facts in a typical long-term disability claim can yield two entirely different, if not opposite, perspectives. The same person, with the same medical and work history, can appear entirely different depending on a reviewer’s perspective. Consider this factual scenario as an example:
A twenty-year employee who has coped with severe and chronic lower back pain for years files a claim for long-term disability benefits. He claims that he can no longer regularly and continuously perform his main job duties on a full or part-time basis. His condition has been the same for at least two years before he stopped working. Simple enough – but look at how this same set of facts can be viewed through different perspectives:
Perspective No. 1: The employee worked through the pain until it became unbearable and very likely long after he should have stopped working and filed a valid claim for benefits. This employee is occupationally disabled.
Perspective No. 2: This employee was working full-time with the same condition before filing a claim for disability benefits. Obviously, he was able to cope with the same condition until he decided to file a claim for disability. This employee could continue working and is not occupationally disabled.
So, how is one supposed to get to the truth of this situation? Medical and Non-Medical Evidence. For a disability claimant fighting his or her way to an approved LTD claim, there is only one way to assure there is but one perspective about the situation – the record as a whole must show there is only one logical perspective once all evidence is taken into consideration. That requires proving one’s own ‘perspective’ while disproving the other’s ‘perspective.’ Definitively.
The question naturally arises, how do you prove a case in the typical disability insurance claim? Here are some basic steps that are required for any successful LTD claim or appeal:
- Secure the administrative claims file of the denied claim. This file, containing a compilation of notes and records, holds the key to understanding the other side’s perspective (be it an insurance company or even employer in certain cases). The information is often invaluable. For example, the administrative record can reveal internal notes of what the insurance company claims is missing from its files and is preventing it from approving a claim. It can show bias, or it can simply show how things have gotten off-track.
- Securing the medical and non-medical documentation proving the validity of the claim. This information is the basis for the claim. It is the treatment notes, test results, and medical opinions of physicians and health providers which serves to medically substantiate the actual claim of disability. Ideally, this information would appear in chronological format explaining the medical changes in one’s condition leading to an inability to work on a consistent and competitive basis.
- Coordinating with treating physicians. Securing the medical records is only part of the requirement of a successful claim. Explaining to treating medical providers that a disability claim is being processed is critical – it may move any request to the front of queue and also communicates the seriousness of any unique response required from a physician. After the initial request, you may discuss how best to coordinate with a treater’s office to timely secure records, test results, completed disability claims forms, and evidence that may be required by legal counsel. See, ERISA Long-term Disability Basics: The Role of the Treating Physician, regarding general communications with your treating physicians regarding disability claims.
- Consulting with or retaining legal counsel. If a case is for total disability, consider retaining legal counsel for consultation or representation to address issues where medical/legal expertise might be needed. Disability cases often present both complex medical and contractual issues. They often require input from experts beyond a client’s treating physicians – even sometimes requiring experts in matters of vocational rehabilitation, physical medicine, or certain objective testing methods. A good lawyer will know this and will incorporate this requirement into the claim or appeal process, if necessary.
- Meeting every deadline – preferably early. Move early, quickly, and effectively toward completing the above steps. Typical due date timeframes can be between 30, 60, 90, or 180 days, depending on the claim.
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