What If My Doctor and the Social Security Administration Say I’m Disabled, Isn’t That Enough?

Unfortunately, no.  As experienced insurance attorneys who have helped many professionals recover the long-term disability (LTD) benefits they were initially denied, we see this often.  A client is deemed “disabled” by either their treating physician or the Social Security Administration (SSA) and they believe this must be sufficient for their LTD insurance carrier to find they are disabled and entitled to benefits, when the answer is: it is not. 

Your Treating Physician's Opinion Is Only a Factor for Your LTD Carrier to Consider

long-term disability insurance claim

When you file a claim for LTD benefits, your LTD carrier will launch an investigation, hiring their own in-house nurse of doctor, who will primarily examine your medical records and the findings of your treating physicians, in addition to statements from your coworkers, colleagues, or family and friends.  Although they will consider the diagnoses and conclusions of your treating physicians, these determinations are not binding on your LTD insurance company.  They will make their own independent determination as to whether you are disabled and entitled to benefits.  The nurse or doctor hired by your LTD carrier may find that the medical records do not support the opinion of your treating physician and so they may disagree in finding you are not disabled even though your treating physician has concluded you are.  While the SSA is required to give your treating physician's determination that you are disabled “great weight,” a private or E.R.I.S.A. carrier must only consider it as one factor. 

The SSA's Determination That You Are Disabled Does Not Control

The standard for determining disability for persons under the age of 50 by the SSA is more stringent than a LTD determination because it follows the “any occupation” standard versus your “own occupation,” discussed further here.  Under an “own occupation” LTD policy, the carrier need only find that you cannot perform your own occupation, sometimes specially defined, not any occupation.  However, to obtain Social Security Disability Income (SSDI), the SSA must find you cannot perform any occupation.  The SSA, however, has slightly different rules governing the determination of disability.  For this reason, your private or E.R.I.S.A. carrier does not have to consider—and will typically ignore—the SSA's determination that you are disabled.  Your LTD carrier, relying on the opinion of the in-house nurse or doctor and its investigation into your medical condition, limitation, and alleged inability to work, will make its own independent determination as to whether are you disabled and entitled to LTD benefits or not.

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