Long Term Disability Exclusions

June 20, 2022 by

There are some long term disability exclusions because long-term disability doesn’t necessarily cover every possible disability condition. When you purchase long-term disability insurance, you may believe you understand the coverage and your policy will cover you for most disability scenarios.

elderly man with long term disability

In fact, nearly all long-term disability policies have specific exclusions for certain conditions. Before you go through the process of applying for long-term disability benefits, carefully review your policy and understand what is and is not covered. You will want to understand the long term disability exclusions in your policy. If you are not sure, then you may want to consult with the Herren Law office in Houston, Texas.

What Is An Exclusion?

This is a clause in your policy that you probably agreed to when you purchased it, or you accepted the policy from your employer. An exclusion details a specific situation where the insurance company does not pay you any monthly income. The idea is to exclude coverage for claims that result from or are related to a pre-existing medical condition, or exclude coverage of any claim that could result from any potentially hazardous activities that can lead to the increased risk of potential disability.

Common exclusions include:

• Pre-existing conditions, which is a condition you already know you have prior to application. This may include some or all pre-existing conditions, depending on your policy.

• Work-related conditions, especially if your occupational injury or illness would otherwise be covered by worker’s compensation benefits.

• Specific health conditions such as cancer, heart disease, lung disease, or diabetes, are detailed in the policy.

• Hazardous or high-risk activities, such as injuries and conditions related to things like bungee jumping and other extreme sports

• A normal pregnancy and delivery

• Acts of war and conflict, such as a riot, insurrection, or another incident of violence

• Other criminal activities

• Self-inflicted injuries. Most policies do not cover any injuries that are self-inflicted or related to a suicide attempt.

Policies with more exclusions generally cost less. The more exclusions you reduce, the higher your premiums. Meaning if it covers more conditions, it will be more expensive as the chances of a claim will also increase.

Mental Health Conditions

Many long-term disability policies also limit or exclude mental health or nervous conditions. This means that if your disability is caused by or contributed to by a mental or nervous condition that’s in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), you may have no benefits or strict limitations on the benefits you can receive.

For policies that do allow for mental health condition claims for disability, the standard limitation is 24 months or two years. Depression, anxiety, stress, and even dementia have a strict 2-year limit in most policies for long-term disability benefits. If you are still disabled because of a mental or nervous condition following the two-year period after your benefit period ends, you will unfortunately no longer be eligible to receive benefit payments.

Alcohol And Substance Abuse

Similar to mental health conditions, many long-term disability insurance policies limit or exclude coverage for any disabilities related to alcohol and substance abuse. Some policies do not cover them at all, but other plans include limitations on how long you could receive benefits.

Handling A Denial

If you think your condition is not a long term disability exclusions, then you apply for benefits.  But even if you are confident your condition is covered under your long-term disability policy, you may be surprised to receive a denial letter from your insurance company. Unfortunately, this is a common occurrence with long-term disability applicants. The good news is you have the right to appeal, so take advantage of it.

Read the letter carefully, and make sure that you understand why your claim was denied. It may be that you did not submit enough medical evidence, or there was something else missing from your claim application. The denial letter will tell you why, and what you need for your claim. However this may also be time to consult an experienced long term disability attorney like Bill Herren. Herren Law Office is a Houston, Texas-based law firm serving clients throughout the greater Houston area. With almost 30 years of experience, they’ve helped over 4,000 people with their disability claims. If you are trying to obtain SSD, LTD, or VA disability benefits, it is beneficial to get help as soon as possible from an experienced disability attorney.

The letter will also let you know about the deadlines for appealing the company’s decision. It is critical to make sure that you meet these deadlines or you’ll lose your right to appeal altogether.

If you believe your insurance company is acting in bad faith, this is also a reason to engage the services of an experienced disability attorney who can help you file your appeal. A good disability attorney understands how insurance companies work, particularly for claims where they will have to pay out money.

Your Houston Long Term Disability Attorney

If you need help filing a long-term disability claim, or are having trouble with the insurer paying your benefits, or need help preparing an appeal to a denial of benefits, we’re here to help.

We’ve helped over 4,000 Houstonians have received the LTD benefits they need. The Herren Law Firm can help you with your application, appeals and help you through the process, and give you one less thing to worry about. Contact us today at 713-682-8194 (or use our online contact form) to schedule your free consultation. There’s no obligation and no up-front fees. We only collect if we win your case.

Filed Under: Long Term Disability Tagged With: , ,

What Happens When An Employee Goes On LTD?

October 5, 2020 by

Long-term disability is a form of insurance that offers an employee a portion of his or her income, usually 50% to 75%, during a recovery period from an illness or accident that isn’t work-related. (Worker’s Compensation covers work-related accidents.)

What Happens When An Employee Goes On LTD?

Statistics from The Council For Disability Awareness indicate that:

  • About 1 in 4 individuals currently 30 years of age will become disabled and out of work about a year before they reach retirement age
  • Most disabling incidents leading to long-term disability are not accidents, but cancer, heart disease, pregnancies, back injuries, and the like
  • About 48% of Americans have enough savings for three months of not working due to disability
  • The average duration of an LTD claim is 34.6 months, nearly three years

Two laws also govern disability leave:

Many long-term disability claimants will fall under one or both of these acts.

An Employer’s Perspective

Even when an employee is out, a company still has work that needs to be done. Temporary and/or contract help may be hired to fill in if the employee has an estimated return date. If the employee is out longer than previously determined or asks for an extension, employers may take a person off the payroll entirely.

Depending on the company, an employer may attempt to hold your job open while you are recuperating, depending on the expected length of your convalescence. Others may have a set time frame by which they will list the job as vacant, and attempt to hire someone else to fill the position. Still, other companies may hold an employee’s position for a specific time, such as a year, before they consider the employee to not return.

Can You Be Fired?

You actually can be terminated, laid off, furloughed, or outright fired while on LTD.

Receiving benefits from an LTD policy does not offer any job security, and your employment job can end for any reason. Your job can be eliminated due to downsizing, or you can be terminated for other job-performance reasons unrelated to your disability.

However, employers must tread carefully when doing so, or risk expensive litigation.

An employee cannot be fired if:

  • He or she is able to do the job with requested reasonable accommodations, but the employer has failed to provide them, whether or not the employee is on FMLA
  • He or she is on FMLA leave, whether or not they can still perform the job under the ADA.

After the 12 weeks of FMLA leave ends, an employee can be terminated. Under the ADA, an employee can request reasonable accommodations. If these accommodations don’t cause hardship, the employer is required to provide them, whether it’s a change in work hours, desk adjustments, or other changes that allow an employee to continue in their job in spite of a disability.

What About Benefits?

What happens to your insurance payments if your employment ends? It depends.

If an insurance company is paying your benefits, chances are that won’t change. But if your company is paying your long-term disability, chances are your benefits will end when your employment does.

You must continue medical treatment in order to keep your LTD benefits but may lose your health insurance in the interim. It’s a conundrum, but continued treatment for your condition is vital for a number of reasons.

This is one of the many reasons to carefully review your policy before applying for long-term disability, especially if your policy is company-provided. You’ll need to know exactly what to expect if things change substantially, such as a downsizing or your company going out of business.

Your Houston LTD Disability Attorney

If you’re facing an absence from work due to a long-term disability, but are having trouble, we’re here to help.

We’ve helped over 4,000 Houstonians have received their LTD benefits. The Herren Law Firm can help you with your application, appeals and help you through the process, and give you one less thing to worry about. Contact us today at 713-682-8194 (or use our online contact form) to schedule your free consultation. There’s no obligation and no up-front fees.  We only collect if we win your case.

Filed Under: Long Term Disability Tagged With: ,

Long Term Disability Death Benefits In Houston, TX

September 16, 2019 by

It’s difficult enough when you or a family member has to apply for long-term disability, especially if there is a terminal or progressive, degenerative illness, such as ALS, or an injury that will never heal. What’s even more difficult to think about is when the time comes that you or your loved one passes away.

But when the day comes, will you receive any death benefits from the LTD policy? This will depend on the terms of the policy, which should be reviewed completely before attempting to apply for LTD disability benefits.

Long Term Disability Death Benefits In Houston, TX

What Is A Death Benefit?

This is a lump sum paid to an insured’s family when the individual dies, and is most commonly associated with life insurance. In fact, life insurance is just that—insurance on someone’s life, which pays out to whomever the insured assigns as a beneficiary.

But with long-term disability, there may or may not be a “death benefit.” Some policies do offer a “survivor benefit” that pays a lump sum of LTD death benefits to survivors for a specific time period, usually one to three months. But as a rule, if the individual has passed away, there is no more need for the insurer to make payments, so they will stop.

If your LTD policy comes through your employer, it may or may not include a death benefit—check your policy. You may have been offered a rider for an additional charge to have that would provide your family or other selected beneficiaries a death benefit.

You may have selected this option for your own LTD policy as well. Again, read and check your policy to be sure, or contact your agent to clarify. You may have the option of adding this type of LTD death benefits, even if you’ve had your policy for some time.

An Alternative LTD: Accelerated Death Benefit

If your LTD insurance is not sufficient, or you are terminally ill and need help immediately, one possibility would be to request an accelerated death benefit on your life insurance policy. There are restrictions on requesting this benefit, and it will reduce the death benefit (total sum of money) paid to your survivors after you die.

You may also use this coverage if you are confined to a nursing home, or are deemed terminally ill. Some policies automatically pay this in circumstances of an imminent death. To qualify, you will have to be certified by a doctor or other medical professional that you are terminally ill, and that death is expected in 12 to 24 months. Some providers set the threshold at six months.

Critical illnesses that can also trigger this benefit include:

  • Stroke
  • Cancer
  • Heart attack
  • Kidney failure
  • Organ transplants
  • ALS

Chronic illnesses are not the same as critical illnesses. To determine if your policy allows an accelerated death benefit for your illness, as always, review your policy and speak with your insurance agent to be sure.

Your Houston LTD Disability Attorney

Long term disability can be an annoying process before you begin receiving benefits. The Herren Law Firm can help you with your application, appeals and help you through the process, and give you and your family peace of mind. Contact us today at 713-682-8194 (or use our online contact form) to schedule your free consultation. There’s no obligation, and no up-front fees, because we will only collect if we win your case.

Filed Under: Long Term Disability Tagged With: , ,
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