Filing an initial claim for Long Term Disability (“LTD”) benefits is very time-consuming and exhausting for claimants. It is a juggling act of balancing the medical care necessitated by your disability, the down time needed for you to rest and heal, and the seemingly never ending requests for information and documents thrust at you by the claims administrator or insurance company. However, it is important to understand that once you are approved for LTD benefits, the juggling act does not stop there. Throughout the duration of your LTD claim, you will be subject to ongoing and period eligibility reviews. During eligibility reviews, the plan or its administrators will be reviewing your evidence to determine if you still meet the test for disability. If during the review, there does not appear to be enough evidence to support disability, your LTD benefits may be denied. Therefore, it is important to understand when such reviews may take place and how to advocate for your claim during an eligibility review in order to avoid wrongful LTD claim denials.
When will your claim be subject to ongoing eligibility reviews?
Unless your LTD plan states otherwise, approved LTD claims are typically subject to ongoing and periodic reviews for eligibility. This means that the insurance company or administrator can contact you throughout the duration of your claim to ask you for ongoing proof of disability including evidence like medical records, income and work documents, independent medical testing, social security documentation, functional capacity testing, and activities of daily living questionnaires. Unless your plan states otherwise, there typically is no schedule for reviews that must be followed or minimum amounts of time that must elapse before another review may be commenced. Pursuant to most LTD plans, when, how often, and for how long ongoing eligibility reviews take place is at the discretion of the plan and/or claims administrators. While an eligibility review and can typically occur at any time during the life of your LTD claim, such reviews most commonly occur when the test for disability changes, as defined by your policy.
Most LTD policies contain a test for disability that changes after the expiration of a period of time. Generally, most LTD policies require you to prove that you are disabled from working at your own occupation for the first 24 months of disability and then after that require you to prove that you are disabled from working in any occupation. You must read your individual LTD policy to determine your test for disability and whether or not it contains this time-based change. However, for policies that contain a time-based change like this, a new eligibility review is almost always commenced in the months leading up to the 24-month test change deadline. Depending on the administrator for your plan, you may even see this test change eligibility review begin as early as 6-9 months before the 24-month test change deadline.
How do you know when your previously approved claim is subject to a new eligibility review?
Unless your plan states otherwise, there is no formal notice that is required to be provided to you to advise that an eligibility review is taking place. However, many insurance companies and administrators do write to you and advise you that they are reviewing your claim for ongoing eligibility. Such letters are often accompanied by requests for documents or a notification that medical records have been requested from your doctors. Even if you have not been informed in writing that you are subject to another eligibility review, there are clues your can look for that often signal a review is taking place. If you have been receiving LTD benefits for some time and then suddenly the following requests or demands are made, it is likely that another eligibility review is taking place:
• Requesting that you or your physicians provide updated medical records;
• Advising you that previous requests for updated medical records were not fulfilled by your medical providers;
• Asking you to fill out an Activities of Daily Living or Disability Questionnaire form;
• Asking your physicians to fill out new Attending Physician Statements or functional impairment forms;
• Realizing that you are be followed or filmed by undercover surveillance agents;
• Receiving phone calls from a claims analyst asking you to provide oral updates on your medical conditions, activity level, daily routine, work history, and income;
• Asking you to allow a representative to interview you at a home visit;
• Requiring you to attend an independent medical evaluation (“IME”);
• Requiring you to attend a functional capacity evaluation (“FCE”); and
• Asking you to fill out functional capacity forms indicating how often and how long you can engage in specific activities.
While the above list is not exhaustive of all of the activities that might take place during an eligibility review, these are some of the key indicators that a new review is underway.
What should you do if you are subject to an LTD eligibility review?
When it comes to your LTD claim, you are your own best advocate and you should never become complacent about your eligibility status. This means that once you believe you are the subject of a new eligibility review, you must spring into action to make sure that all requests made by the insurance company for records, evidence, evaluations and testing are complied with fully. You should never assume that just because a letter requesting medical records or other documents was sent directly to your treating physician’s office that the office or physician will actually fulfill that request. One of the most common reasons that LTD benefits are denied during an eligibility review is because the medical provider failed to send updated medical records or failed to fill out a new attending physician statement as requested. Below are actions you can take to make sure that your LTD benefits are not denied as a result of an eligibility review:
• Do not become defensive or obstructive. During eligibility reviews most LTD claimants feel as if they are being harassed, picked on, or singled out by the insurance company or a claims analyst. As a result, they sometimes refuse to comply with requests, get argumentative with claims analysts, or do not bother to send in additional documents. Remember, claims analysts typically maintain notes about all of your conversations and you do not want to give them the opportunity to fill your administrative record with disparaging notes. Further, unless there is a provision in your policy prohibiting the actions or requests taking place, there is likely nothing you can do to prevent it. Ignoring or refusing requests for information or documents will almost always cause your LTD claim to be denied.
• Timely comply with all requests for documents and information. It is your responsibility to ensure that all medical records and documents requested are gathered and returned to the insurance company in a timely manner. If your disability causes you difficulty with your ability to gather and submit documents, you should contact your claims administrator and explain this or ask for additional time to submit documents if necessary. You should always keep a copy of anything you send in for your claim, with proof it was sent, in case it does not reach the appropriate claim analyst and you need to resend it.
• Follow up with your medical providers to make sure that they complied with all requests for documents or information. If you ever receive a letter indicating that your medical provider has not complied with a request for documents, you should immediately contact that provider about the issue. You must explain to your medical providers that if they do not comply with the ongoing requests for documents and information, your LTD benefits, and thus your monthly income and ability to pay for your medical care, may end. If you have concerns that your provider will not comply with the request, you should collect and send in the documents on your own. You may contact your doctor’s office or medical records department directly for information about how to request your medical records.
• Comply with all requests for IME’s and FCE’s. It may feel harassing or unnecessary to have to attend IME’s and FCE’s; however, if you refuse to attend you may be denied your LTD benefits. Before you attend, you should check with your treating physician to make sure that you are medically cleared to attend the evaluation or test. If you are not cleared by your treating physician to attend, you should inform the claims administrator and ask your treating physician to submit a written explanation of why you may not attend. If you are cleared to attend, you should ask to receive a copy of all IME and FCE reports so that you may review the medical information that the insurance company is collecting about you. Do not be surprised if you get resistance to such requests as some insurance companies have a policy that they will not release this information to you until the eligibility review is complete.
Remember, when it comes to ongoing eligibility reviews, you are solely responsible for ensuring that all requests for additional information are completed. If you become complacent or assume requests for information are being taken care of, you are putting your LTD benefits at risk. You must be the champion of your LTD claim.
ABOUT THE AUTHOR: Attorney Elizabeth Schmidt, Alan C. Olson & Associates, S.C.
Attorney Elizabeth Schmidt’s practice is devoted exclusively to the representation of plaintiffs in employment law and disability benefits matters. Attorney Schmidt advocates for the right of employees to receive wages, be free from discrimination, and have a safe and healthy work environment. Attorney Schmidt represents employees exclusively in employment law matters under state and federal laws including the Wisconsin Fair Employment Act, Americans with Disabilities Act, Age Discrimination in Employment Act, Family Medical Leave Act, Fair Labor Standards Act, and Title VII. I also assist clients in the pursuit of short-term and long-term disability benefits, including filing lawsuits under state and federal laws and ERISA. Attorney Schmidt works closely with each client to ascertain their individual goals and provide the information necessary to make informed decisions. Attorney Schmidt believes communication is the key to obtaining successful outcomes and client satisfaction.