When you suffer an injury or contract an illness that results in a long-term disability, you expect your insurance company to pay you the benefits the policy promised. That’s why you bought the policy. When you file your claim, however, you may discover that your insurance company is not the friend you thought it was.
To successfully file a long-term disability claim, you must have some type of disabling condition and the proper medical documentation to substantiate it. Almost all policies require that disability be caused by an injury or a sickness, but check your own policy carefully to make sure you understand exactly what your policy requires. Then set about substantiating your claim.
The first thing you’ll need is a proper diagnosis; i.e., a statement from your doctor or other health care professional defining the name and nature of your illness or injury, such as spinal stenosis, Lyme disease, fibromyalgia, coronary artery disease, bilateral carpal tunnel syndrome, etc. This statement likewise should include your doctor’s proposed treatment plan, your overall prognosis, and your physical and mental restrictions and limitations.
The doctor or other health care professional you choose must be qualified in the specific medical discipline into which your injury or illness falls. For instance, getting a statement from your primary care physician that you have fibromyalgia generally will not be sufficient to support your long-term disability claim. Instead, you need a statement from a rheumatologist, a doctor who has the requisite expertise to make such a diagnosis.
One thing you should be aware of is what is often called the “surgeon conundrum.” If you had surgery due to your injury or illness, your surgeon may not be the best physician to substantiate your long-term disability claim. Why? Because surgeons perform surgery; they don’t provide follow-up care if your disabling condition persists on a long term basis following the surgery and expected recovery date.
When choosing the health care professional properly qualified to diagnose your condition, make sure that (s)he also is willing to become your advocate in your long-term disability claim. Insurance companies usually require “mountains” of paperwork to substantiate your claim, and they almost always have their own forms, such as an attending physician’s statement, that they expect your physician to properly and completely fill out. Choosing a physician who is willing and able to provide all the necessary information your insurance company requests, in the format they request it, is a critical component to the success of your claim.
Evan S. Schwartz
Founder of Schwartz, Conroy & Hack