Long Term Disability Exclusions

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 SSDLTD, 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.

What Happens At A Disability Hearing In Houston?

Your first encounter with a disability hearing may be intimidating. It can be awkward discussing your life with complete strangers who are deciding whether or not you are qualified to receive a disability.

If this is your first time dealing with Social Security in person, understand that it’s not the same as appearing in court. Although the hearing is important, it’s an informal hearing, and usually doesn’t last longer than an hour. The hearings are not open to the public as a court case is, and anyone with you (other than your attorney) is required to wait outside.

What Happens At A Disability Hearing In Houston?

This hearing is to determine the extent of your disability, and if your disability prevents you from working. The judge will ask questions to get a better idea of your condition. It’s important to answer the questions honestly and thoroughly, but don’t exaggerate or lie about anything.

What Questions Will They Ask?

Because the hearing revolves around what you can and can’t do, and why you can’t work, expect the questions to be focused on those points. You’ll likely be asked questions such as:

  • Are you working currently?
  • Why can’t you work?
  • What was your last job, and what were your responsibilities?
  • Have you tried working since you became disabled?
  • What type of formal education do you have?
  • Do you have any vocational training?
  • Where else have you worked in the last 15 years? What were those job responsibilities?
  • Do you have any problems getting along with coworkers, supervisors, customers or clients?
  • How much can you lift at one time?
  • How long can you walk, sit, or sit before you require a break?
  • How often do you need to take a break?
  • Do you have difficulties with concentration or remembering anything?
  • What effect does your disability have on your daily activities?
  • What activities do you do?
  • How does your disability affect your ability to take care of yourself?
  • What have you been diagnosed with?
  • What medical treatments have you had?
  • Are there any side effects to these treatments?

These are just some of the types of questions you may be asked. Of course, it’s important to be ready for any of these questions as well as others.

Being Prepared For The Disability Hearing

The time leading up to the hearing can be downright nerve-wracking, leading to rambling and over-answering a question—or saying something you shouldn’t. Avoid this possibility with some pre-hearing research and rehearsal.

Spend some time reviewing:

  • Your case file
  • Medical and Job Worksheet (Form SSA-3381), filled out before your application for disability
  • Your most recent medical records
  • Statements and expert medical opinions from family members, friends, coworkers and supervisors, as well as your doctor or any doctor you’ve seen regarding your condition (such as a neurologist or orthopedic surgeon.) These statements should describe your disability and how it affects you daily.

You’ll also need to provide copies of your medical records and medical opinions to the judge prior to the hearing. Keep copies for yourself as well.

Make notes using the above questions, as well as any your disability attorney might mention before the hearing. And of course, take these documents and notes along with you to the hearing.

Houston’s Disability Attorney

A disability hearing can be daunting, but it doesn’t have to be. Having an experienced disability lawyer can make the hearing—and the process—easier for you. If you are unfamiliar with the system and don’t get help, a judge can make decisions based on their own opinion, leaving you with no options for challenging them.

Let The Herren Law Firm in Houston, TX assist with your application, appeals, and records gathering to prove your case, and help win your claim. 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, and we only collect a fee if we win your case.



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