Reasons for Denial of Long-Term Disability After Two Years

When you filed for your long-term disability (LTD) benefits, you likely had to prove that you were totally disabled. Most insurance companies define “totally disabled” as being unable to perform the essential tasks necessary to do your own job.

It has now been two years since you were approved for long-term disability benefits, and the insurance company has notified you that it is re-evaluating your eligibility for long-term disability benefits. Nothing has changed regarding your condition in the past two years, so why is the insurance company cutting off benefits now? Our Kansas City long-term disability lawyer explains why this might be happening in your case.

The Definition of Disabled Changes After Two Years from “Own Occupation” to “Any Occupation”

Being re-evaluated means that you must go through the process of proving that you are disabled again. Why is the insurance company doing this after two years?

For most long-term disability insurance policies, you meet the definition of being totally disabled for the first two years if you cannot perform the duties required to do your “own” job. This standard is referred to as the “Own Occupation Test.” The first two years you receive long-term disability benefits are often referred to as the “own occ” period of the policy.

For example, a construction worker injures his back. Because of the back injury, the construction worker cannot bend and lift objects. Therefore, the insurance company determined the worker was totally disabled because he could not perform the material tasks required to perform his own job.

However, after two years, the criteria for being totally disabled shifts to an “Any Occupation Test” or “any occ” period. The insurance company re-evaluates your claim to determine if your disabling condition allows you to perform the job duties for any occupation. Instead of limiting the consideration to the job duties required to perform construction work, the insurance company evaluates you based on any job.

For instance, the insurance company might state that you cannot bend and lift heavy objects to perform construction work, but you could work at a desk reviewing construction drawings or ordering supplies. However, the evaluation is not limited to just your field of work. The insurance company can evaluate your ability to perform work in any field to determine if you meet the definition of totally disabled after two years.

There could be other reasons the long-term disability insurance company is denying long-term disability benefits.

Two Year LTD Limits for Certain Disabling Conditions

Your long-term disability benefits may stop after two years based on the type of disabling condition you have that resulted in long-term disability payments. For instance, most long-term disability insurance policies place a two-year limit on disabilities resulting from drug abuse or alcohol abuse.

These group policies also have a two-year limit on long-term disability benefits for many disabilities based on nervous, mental, or psychological impairments. That would include disability benefits based on PTSD (post-traumatic stress disorder), depression, anxiety, and other mental and emotional disorders.

The reasoning is that many of these disorders can be “faked” or exaggerated. You can receive up to 24 months of long-term disability benefits and then the benefits stop. However, if you are receiving inpatient treatment for the condition, the insurance company might continue to pay benefits until you reach a cap for benefits.

In some cases, there could be exceptions to the two-year limitation on mental disorders. Suppose you have proof that you suffer from an organic brain disorder or neurocognitive disorder, such as Bi-Polar disorder, dementia, or schizophrenia. In that case, you could receive long-term disability benefits past the two-year cutoff. However, you will need medical proof that you suffer from one of the conditions exempted from the two-year limitation.

Many long-term disability insurance policies also include a two-year limitation for benefits paid for chronic pain disorders and other health conditions based on subjective symptoms such as fibromyalgia and chronic fatigue syndrome. The limitation may include many soft tissue and neuromusculoskeletal disorders. Some policies may include an exemption for certain disorders that have objective medical evidence to support the disability.

Long-term Disability Insurance Defines Disability Differently from the Social Security Administration

Many individuals are shocked when their LTD benefits end because they were approved for disability benefits under Social Security. However, the Social Security Administration’s definition of disabled is different from the criteria used by long-term disability insurance companies to determine if you are disabled.

A person may be eligible for Social Security disability benefits if they cannot perform the work they did before developing a disabling condition, the condition is expected to last at least one year or longer, and they cannot adjust to other work because of their disability.

However, long-term disability insurance companies are not required to use this definition of disabled. Therefore, your long-term disability benefits may be terminated under the insurance policy even though the Social Security Administration ruled that you were disabled based on their criteria for totally disabled.

How Can the LTD Insurance Company Prove I Can Work After Two Years?

a transferable skills analysis performed by a vocational expert hired by your long term disability insurance company will determine if you can work again after a shift in career The insurance company hires a vocational expert to review your case. A vocational expert performs a Transferable Skills Analysis or TSA based on the information in your file. The TSA is a computer analysis used to determine what skills you have that could be transferable to another job. For example, do you have skills that could transfer to a job that requires little physical labor (a sedentary job)?

The vocational expert creates a report that outlines your ability to perform physical labor. Suppose the TSA finds that you can transition into a sedentary job. In that case, the report lists jobs that you are qualified to perform, considering any limitations of your disabling condition. If the vocational expert determines you can perform any job, the long-term disability insurance company cancels your disability benefits.

What to Do If I Receive Notice That My Long-Term Disability Benefits Stop After Two Years?

Contact a long-term disability attorney immediately to discuss your options for appealing the decision. You must quickly act because your time to appeal the decision is limited. Failing to file the appeal before the deadline is one of the most common mistakes made by individuals whose long-term disability benefits are cut off after two years.

LTD insurance companies use vocational reports to stop long-term disability payments after two years. These reports may not consider that you have a degenerative disease that will continue to worsen with time. Also, insurance companies may hire vocational experts, doctors, claims adjusters, and investigators who are more likely to side with the insurance company instead of the claimant.

Appeal a Denial of Benefits with Help from a Long-Term Disability Attorney

You can fight a long-term disability denial of benefits and win. However, you need help from a skilled, experienced long-term disability lawyer. Disability attorneys who work only with Social Security disability benefits may not have the experience and knowledge required to handle these claims. You need an attorney with experience handling ERISA-based long-term disability claims.

At the Law Office of Kevin J. McManus, we have substantial experience handling LTD appeals subject to ERISA laws and regulations. If you receive notice that your LTD benefits will stop after two years, contact our office to talk with an attorney about your options for appealing the decision. Call 816-203-0143 or complete our online contact form for more information about long-term disability appeals.

 

Kevin J. McManus
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Kevin McManus is a nationally recognized personal injury and long-term disability attorney in Kansas City, MO.