Long Term Disability: Does Your Claimant’s Condition Qualify?

When handling long term disability (LTD) claims, one of the most critical questions adjusters and case managers face is: Does this claimant’s condition qualify under the policy’s criteria? Determining eligibility isn’t just about checking boxes; it’s about fairness, and compliance while protecting from fraudulent claims. Let’s break it down.

Understanding the Policy Language

Every LTD policy has specific criteria that define what qualifies as a disabling condition. Some key components to look for include:

• Definition of Disability: Does the policy use “own occupation” or “any occupation” as the standard? An “own occupation” definition focuses on whether the claimant can perform their specific job, while “any occupation” considers whether they can perform any job for which they are reasonably qualified.
• Medical Evidence Requirements: Policies typically require objective medical evidence, such as diagnostic tests, physician statements, and treatment records.
• Exclusions and Limitations: Look for conditions often excluded, like self-reported symptoms (e.g., chronic fatigue, migraines) or mental health limitations, which may have capped benefit periods.

Key Steps to Verify a Claimant’s Condition

To ensure a thorough evaluation, follow these steps:

Gather Comprehensive Medical Records

Request all relevant medical records, including diagnostic tests, treatment plans, and progress notes. These documents are the foundation for assessing whether the condition meets the policy’s criteria.

Use Independent Medical Examinations (IMEs)

An IME provides an unbiased evaluation of the claimant’s condition. This is especially valuable when there are discrepancies between the claimant’s reported limitations and the medical evidence.

Conduct Vocational Assessments

A vocational expert can evaluate whether the claimant has transferable skills that could enable them to work in another capacity, even if they can’t return to their previous role.

Monitor for Red Flags

Be on the lookout for:
• Inconsistent Statements: Do the claimant’s descriptions of their limitations vary across interviews, medical records, or social media?
• Lack of Objective Evidence: Are the symptoms subjective without supporting medical tests?
• Gaps in Treatment: Is the claimant following the prescribed treatment plan?

Exclusions and Limitations That Can Directly Affect Eligibility

When reviewing long-term disability (LTD) claims, exclusions and limitations within the policy play a pivotal role in determining eligibility. Understanding these clauses helps adjusters and case managers make informed, fair, and policy-compliant decisions. Below are some key scenarios to consider:

• Pre-existing Conditions: A pre-existing condition is typically any medical condition or illness the claimant was diagnosed with, treated for, or showed symptoms of before the LTD policy’s effective date.
• Policy Language: Most policies include a “look-back period,” often ranging from 3 to 12 months, during which the claimant’s medical history is reviewed. It can be difficult to determine whether a condition is truly pre-existing, especially if symptoms were present but undiagnosed. To accurately verify, claims adjusters should scrutinize medical records, timelines, and policy terms to determine applicability.
• Subjective Conditions: These conditions rely primarily on self-reported symptoms, such as chronic pain, fibromyalgia, or chronic fatigue syndrome. Policies may restrict benefits for such conditions unless supported by objective medical evidence, such as Functional Capacity Evaluations (FCEs) or Independent Medical Examinations (IMEs). Without objective evidence, it can be difficult to differentiate valid claims from exaggerated or fraudulent ones.
• Occupational Exclusions: Some policies exclude coverage for injuries or illnesses related to specific high-risk occupations or activities. Pilots, professional athletes, or hazardous duty workers may face exclusions unless their policy explicitly includes coverage for occupational risks.

Tools and Services to Streamline Verification

Modern claims management tools can make your job easier:
• AI-Powered Fraud Detection: Flags suspicious patterns.
• Integrated Claims Platforms: Centralizes medical records, assessments, and communications.
• Surveillance and Social Media Monitoring: Validates claimant-reported limitations.

Determining whether a claimant’s condition qualifies for long-term disability benefits is both an art and a science. By understanding policy details, leveraging objective evaluations, and proactively addressing red flags, you can make informed decisions that balance fairness with financial responsibility. Remember: Behind every claim is a person. While it’s essential to protect against fraud, compassion, and clarity in communication go a long way in building trust with claimants.

Reach out to our in-house disability claim experts about any questions you have regarding disability claim verification.

Check out our sources:
National Association of Insurance Commissioners (NAIC)
U.S. Department of Labor
Disability Management Employer Coalition (DMEC)