| Legal Issues: Long-Term Disability
Long-term disability (LTD) insurance protects workers
in the event
they become disabled prior to retirement. Many LTD policies are offered through employers as part of a
standard benefits package, while others are purchased directly from insurance companies.
Obtaining benefits for chronic fatigue
and immune dysfunction syndrome
(CFIDS) can be difficult, as insurance companies are reluctant to pay benefits for a condition that can
be hard to prove through objective testing.
Proof of Disability
To obtain benefits, claimants
must first prove that they are disabled, per the requirements of their individual policies. In the case
of CFIDS, this can be complicated, as some policies require "objective proof" of disability before payment
can begin. Other policies have two-year limits for mental or nervous conditions, so many insurers attempt
to erroneously classify CFIDS as a psychological condition to limit their financial liability.
To prove disability, patients must
have the support of their physicians.
Many find that they must go to expensive CFIDS specialists for the sole purpose of documenting the disability
their personal physicians have observed. Some tests that have been used to objectively prove disability
due to CFIDS are exercise capacity tests, tilt-table tests
and advanced
neurocognitive
assessments.
Types of Disability
Policies
There are three main
types of disability coverage:
- Own-occupation plans compensate when you
can't work in your current profession (this is the most lenient definition of disability).
- Education, training and experience plans
compensate when you can't work in any job for which you are qualified by education, training and experience.
- Any-occupation plans compensate when you
can't work in any job. This definition is similar to Social Security's definition
of disability, and is the most stringent type of policy.
Before applying for disability, claimants
should obtain a complete
copy of their insurance policies, including the definition of disability section, and review it carefully
to make certain their claims meet the plans' requirements.
Protect Yourself
- Document all communications with anyone involved in your LTD claim.
All telephone calls should be followed with a letter re-stating the conversation. Keep copies of this
and other relevant correspondence, including postmarked envelopes from the insurance company, in a file.
- Most insurers will require that claimants go for an "Independent
Medical Exam" (IME). Remember that IMEs are paid by the insurance company to evaluate your disability.
It is wise to bring a friend or family member (preferably someone with a medical background) to an IME
to document the visit, help ask questions (especially when you are having a bad day cognitively) and
check the IME's report for inaccuracies.
- It is common for LTD companies to employ investigators to observe
claimants as part of their fraud-prevention strategy. Don't be surprised if you are videotaped, visited
or secretly watched and make sure to keep brief notes on your daily activities and symptoms in the event
the insurance company uses surveillance to deny or revoke your benefits. (Your doctor may also find these
records helpful in designing your treatment plan.)
Legal Concerns
Employer-sponsored LTD plans are governed by
a federal law called ERISA (Employee Retirement Income Security Act). This is the same law that governs
employer-sponsored health and pension plans.
Originally written to protect employee benefit plans, it has an
unfortunate loophole in that it is legally difficult for dissatisfied claimants to take their cases to
court. Many CFIDS patients who have been denied benefits by their LTD plans have complained
that ERISA gives insurance companies an advantage. Because claimants can usually only recover back benefits
(and not
damages), attorneys may be reluctant to take these difficult cases. For more information on
your legal rights
and seeking an attorney in LTD cases, see Finding an Attorney.
Privately purchased LTD policies are
not subject to ERISA and claimants
are permitted to take their cases to court. Unfortunately it is very expensive to pursue legal action
against large insurers, so many CFIDS patients find it almost as difficult to pursue lawsuits in these
cases as it is in ERISA cases.
Complaints about handling of LTD claims
can be made to the U.S. Department
of Labor's Employee Benefits Security Administration,
your state's insurance commission and your
representatives in Congress.
Often, LTD companies require
successful claimants to apply
for
Social Security benefits and will reduce their payments by the amount SSA pays. Having SSA declare you
disabled may provide additional support for a LTD claim, even though SSA's definition of disability is
different than most private companies'. For this reason, you may wish to submit a SSA disability claim
at the same time you submit a request for LTD benefits.
An additional benefit to having SSA
disability benefits is
that after two years you become eligible for Medicare, the federal government's
health insurance program for the elderly and disabled. For CFIDS patients who
have no other medical insurance, this benefit can be as important as the cash benefits they receive from
SSA.
The
CFIDS Association of America has other resources for people interested in disability and CFIDS. Please
use the
Search feature at left to access many of those resources.
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