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Diseases that Qualify for Long-Term Disability Benefits

Appealing for benefits is best done under the guidance of an experienced disability lawyer.

What disabling impairments qualify for Long-Term Disability Insurance?

Author: Attorney Lonnie Roach

If you have been forced to stop working due to a disabling disease, you should investigate whether you are covered for disability benefits under a Long Term Disability (LTD) policy.

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Virtually any disease or condition can qualify as a disabling condition for the purpose of receiving LTD benefits. If you have a question as to whether your condition qualifies under your particular policy, feel free to contact us. We’re happy to answer your questions. 512-454-4000

According to the Social Security Administration, 1 in 4 people will be disabled before they reach age 67.

Sustaining an injury or contracting a chronic illness can devastate a family’s or an individual’s finances. Long term disability insurance can protect an employee from loss of income in the event they cannot work due to illness or injury by providing a percentage of their salary. Long term disability insurance can be obtained through an employer, a group or organization, or purchased privately and typically provides 50% to 70% of an employee’s regular wages. Coverage begins 10 to 53 weeks after an employee is not able to work and can last 5 to 10 years or as long as an employee is disabled until they reach age 65.

There are many medical conditions which may entitle a person to long term disability insurance benefits, not just injuries from accidents.

Chronic illnesses, some degenerative diseases, and neurological disorders can prevent a person from working. Some examples of medical conditions that may qualify as disabling include:

  •   Cancer
  •   Lupus
  •   Chronic Fatigue Syndrome
  •   HIV/AIDS
  •   Bi-polar Disorder
  •   Multiple Sclerosis
  •   Back Injuries
  •   Rheumatoid Arthritis
  •   Knee Injuries
  •   Seizure Disorders

Each long-term disability insurance policy is different.

If you are considering filing a claim, the first – and most important – step you must take is to thoroughly review your policy or consult your HR representative for the policy’s precise definition of disability. Usually an employee is found totally disabled if they are unable to substantially perform the important duties of their occupation due to illness or injury. Some LTD policies allow for “partial disability,” where an employee is unable to work full-time at their own occupation, even if the employee is capable or working full or part-time at another job.” This is how disability is defined under one Cigna long term disability insurance plan:

If you have been denied long-term disability don’t give up! Contact a Disability lawyer at 512-454-4000 for a free consultation and get the benefits you deserve.

To receive benefits under this plan, you must be disabled (as defined below) as a result of a covered injury or sickness, and you must be under the appropriate care of a licensed, practicing physician who is qualified to treat your disability.

Disabled means that, solely because of a covered injury or sickness, you are unable to perform the material duties of your regular occupation or you are unable to earn 80% or more of your indexed earnings from working in your regular occupation. After benefits have been payable for 24 months, you are considered disabled if solely due to your injury or sickness, you are unable to perform the material duties of any occupation for which you are (or may reasonably become) qualified by education, training or experience, or you are unable to earn 60% or more of your indexed earnings. We will require proof of earnings and continued disability. Injury means any accidental loss or bodily harm that results directly and independently of all other causes from an accident. Sickness means any physical or mental illness. Appropriate Care means the determination of an accurate and medically supported diagnosis of your disability, or ongoing medical treatment and care of your disability by a physician that conforms to generally accepted medical standards, including frequency of treatment and care. Regular Occupation means the occupation you routinely perform at the time your disability begins. In evaluating your disability, the insurance company will consider the duties of your occupation as it is normally performed in the general labor market in the national economy. It is not work tasks that are performed for a specific employer or at a specific location. Physician means a licensed doctor practicing within the scope of his/her license and rendering care and treatment to an employee that is appropriate for the condition and locality. A physician cannot be the employee, his/her spouse, the immediate family of either the employee or spouse, or a person living in the employee’s household.

While each policy is unique with its own definitions and terms, many LTD companies defer to the definitions and standards for disabling medical conditions in the Social Security Administration’s Blue Book where disabling injuries and illnesses are listed in the following categories:

  •   1.00 Musculoskeletal System
  •   2.00 Special Senses and Speech
  •   3.00 Respiratory Disorders
  •   4.00 Cardiovascular System
  •   5.00 Digestive System
  •   6.00 Genitourinary Disorders
  •   7.00 Hematological Disorders
  •   8.00 Skin Disorders
  •   9.00 Endocrine Disorders
  •   10.00 Congenital Disorders that Affect Multiple Body Systems
  •   11.00 Neurological Disorders
  •   12.00 Mental Disorders
  •   13.00 Cancer (Malignant Neoplastic Diseases)
  •   14.00 Immune System Disorders

Whether or not you qualify for LTD benefits will depend on how your condition affects your ability to perform your job.

For example, if you suffer from arrhythmias, but your condition only causes mild discomfort and arrhythmias only occur about once each month, it is likely you won’t miss work often and you will only need to use sick days. But if your medical condition prevents you from driving or interferes with your work performance because of fatigue or inability to concentrate, you may qualify for LTD benefits. Keep in mind that some policies may exclude pre-existing conditions – illness or injuries that were diagnosed or treated before the LTD insurance coverage began. Additionally, some policies will not cover particular illnesses, such as mental disorders or conditions caused by alcoholism or drug abuse. You will need to provide statements from your treating physician as well as all clinic notes, laboratory results, x-rays, MRIs, exam findings and surgical reports. You should also show that you are continuing to receive treatment to prove that your disability is ongoing; failure to continue treatment may be grounds to cut off your LTD benefits.

Filing a claim for long-term disability insurance is a complicated process.

The terms and wording in policies can be confusing and the laws and regulations affecting the types of LTD insurance differ in their procedures for filing claims and appeals. While LTD insurance purchased through a private insurance broker is governed by state contract and bad faith law, group LTD policies are regulated by the Employee Retirement Income Security Act (or ERISA). That is why it’s important to consult with a dedicated LTD attorney when filing a claim for disability. An LTD lawyer who has thorough knowledge of these laws and regulations and experience with LTD insurance companies and policies can be essential in ensuring you get the benefits you are entitled to.

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Disability benefits are an important source of income for those who are unable to work. If you are not able to work due to accident or illness, you may be eligible for Social Security Disability or Long Term Disability benefits. If you have applied for benefits and been denied, contact the attorneys at Bemis, Roach and Reed for a free consultation. Call 512-454-4000 and get help NOW.

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"Words can not truly express the gratitude that I feel toward Mr. Lonnie Roach and his professional team. I give them an A+++. Very compassionate and prompt. Their priorities are first and foremost helping you succeed at your case. When you feel helpless, feeling like someone is on your side can mean the world to you. Thank you for working for the people."
-Amy K.

Attorney Lonnie RoachAuthor: Attorney Lonnie Roach has been practicing law for over 29 years. He is Superlawyers rated by Thomson Reuters and is Top AV Preeminent® and Client Champion rated by Martindale Hubbell. Through his extensive litigation Mr. Roach obtained board certifications from the Texas Board of Legal Specialization. Lonnie is admitted to practice in the United States District Court - all Texas Districts and the U.S. Court of Appeals, Fifth Circuit. Highly experienced in Long Term Disability denials and appeals governed by the “ERISA” Mr. Roach is a member of the Texas Trial Lawyers Association, Austin Bar Association, and is a past the director of the Capital Area Trial Lawyers Association (Director 1999-2005) Mr. Roach and all the members of Bemis, Roach & Reed have been active participants in the Travis County Lawyer referral service.

Disabling Diseases

Bemis, Roach & Reed has helped clients who are disabled from a wide variety of medical conditions. If you are unable to work due to any of the following conditions and have been denied disability benefits, contact us. We would like to help.

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