Long Term Disability (LTD) APPLICATION PROCESS
This document is a checklist provided to walk you through the LTD application process. As you read, and complete each section, check it off so that you can keep track of where you are in the process.
What and Why LTD?
Long Term Disability (LTD) is defined as a severe illness or injury that prevents you from working at all or prevents you from working full-time, for a period of six months or longer.
The purpose of an LTD plan is to protect you and your family from complete loss of income should you suffer a long term disability.
This “How-To” document summarizes a generic Long Term Disability application process in everyday language and explains how and when to apply for benefits. Please refer to your LTD Summary Plan Description as you proceed through this checklist.
LTD plans usually are provided in two ways:
v Paid for by a company as part of the company’s employee benefit package; and,
v Paid for by a person as an individual insurance plan
q My LTD plan is: Company paid; Self paid.
q I am eligible for LTD.
A long term disability plan usually covers a physical or mental illness that prevents employees from performing the job that they occupied at the time the illness/accident occurred.
To be eligible, a plan participant usually has to meet at least three conditions:
1. S/he has been covered (i.e., have worked for the company, or have owned the policy) for the length of time prescribed in the SPD;
2. S/he expects the condition to last at least a specific period of time (usually, longer than the short term disability plan lasts – six to twelve months); and,
3. The “triggering” illness/accident is both the specific reason that you cannot do your job, and, the impact is that you have lost “work pay”.
A wide range of conditions usually are covered, including (but not limited to):
• progressive, uncontrolled cancer;
• loss of major functions of arms and/or legs;
• serious brain damage;
• alcohol or drug addiction;
• and severe mental illness.
q Is there a pre-existing restriction for illness or injury in your plan?
q If yes, does it apply to you? Yes No
Some plans have a pre-existing condition provision. That is, if you were treated (or if a prudent person would have been treated) for a condition within 3 months prior to entering the plan, long term disability benefits would not be available during the first 12 months of coverage for that condition only. Coverage would be immediately available for other conditions.
q I understand how my LTD plan works.
Usually, under an LTD, monthly benefits are paid to the qualified applicant who is totally or partially disabled for a period longer than a specific number of days. That first period of time is called the waiting or elimination period, and no benefits are paid during that time. Often, the STD or Short Term Disability plan covers this period of time, or, a combination of STD coverage and sick leave. (Check the STD checklist for further information.)
q My LTD Plan elimination period is _______________ days. I will obtain income during this time through the use of: ________________________________________________________
q My LTD benefits will last until: ____________________.
Disability benefits usually continue until the earlier of the date that you complete the maximum benefit period, are able to return to work (see below the difference between work of “own occupation”, or “work of any occupation”), retire or die. Assuming that your retirement age will be age 65 or older, your LTD benefits, once received, should last until you are able to return to work; you retire; or you die, unless the plan specifies another date. Some plans offer benefits until age 70, for example.
q My LTD benefits will equal _______% of my pre-incident monthly income, or _____________.
q I have the other types and amount of income that will deducted from my LTD monthly income:
q Worker’s compensation:______________
q Social Security Disability Income:____________
q Third Party Disability:_____________
The monthly benefit is equal to a certain percentage of your basic monthly pre-incident earnings, minus the amount of certain other types of income you receive, such as Social Security or third party disability payments and Workers' Compensation benefits. If you are partially disabled, partial benefits may be payable.
q There are other conditions in my LTD plan that I must be aware of. They are: _________________________________________________________
For example: in some plans you may find that you can still be covered, and remain in a pay status, if the illness “goes away” for a short (usually, 30 days) period of time. The only time this is not applicable, usually, is if this “illness break” occurs during the elimination period. That means, if, during your, say 120 day elimination period before receiving income from your LTD policy, you have an “illness break” of two weeks, that two week time frame extends your 120 day time frame an additional two weeks.
q My LTD “days” are: week days only; calendar days.
q I must use my accumulated/accrued sick leave during my elimination period. Yes No
q I must use my accumulated/accrued vacation time during my elimination period. Yes No
q My sick leave days are:___________________
q My vacation days are:____________________
Check your SPD to see if you are required to use all the sick/vacation leave you have built up. If you must take them, use them for income during your LTD elimination time frame.
UNDERSTANDING THE LTD FORM
Prior to working on the actual LTD form, it is important to remember that this is an INSURANCE PROCESS. What this means, is, that you are preparing to “convince” your LTD insurance company that you have an illness or accident that keeps you from doing your “job”; because of this, you do not receive pay for work performed.
Earlier, we mentioned two types of “job”. They are:
1. Your own, or your “pre-incident” job or occupation; and
2. ANY job that your age, education, and prior work experience qualifies you to perform.
Your SPD will tell you how long your LTD insurance will cover you from being able to perform your own job, and any job.
q My LTD insurance will pay me for not being able to perform “my own occupation”, which is: ____________________________________ ; for ___________.
q My LTD insurance will pay me for not being able to perform “any occupation” beginning: _______________________________.
DOCUMENTING YOUR INABILITY TO PERFORM YOUR “OWN OCCUPATION”
The first thing you need to review is your own job description. Hopefully, your job description will contain what is called “physical capacity criteria” that indicate what specific physical, mental, and social “levels of interaction” are required when performing your job. (See attachment ----, an example of a job description that includes the physical capacity criteria.)
If your job description does not include such criteria, you will need to develop them. For example, in your job:
1. If you need to use a computer, this activity could require you to be able to carry out small motor skills proficiently for 2-4 hours per day, or longer.
2. In using this computer, you would be required to sit for 2-4, and up to 6 hours per day.
3. In using this computer, you would be required to have visual skills capable of viewing a computer screen for 2-6 hours per day.
4. If your job requires you to inspect a warehouse, this activity requires you to walk for 2-4 hours at a time; for distances up to 2 miles; to conduct activities in a non-office work environment that could reflect temperature differences between heat and cold.
5. This warehouse inspection could require you to climb the equivalent of 5 flights of stairs at least 4 times per day.
6. As a Welder of iron plating, you could be required to stand, sit, bend, for 4-7 hours per day.
These are just a few examples of how activities of a job correlate to the physical activities of normal daily living. What you need to do is to develop the physical requirements of your job. Please see appendix___________ as an example.
q I have developed the physical requirements of my job.
q I have provided a copy of these requirements to both my supervisor, and to the appropriate person in my company’s human resources department. Both have signed off on the document that it is accurate.
Your next step is to complete the “Before and After” activity matrix found at attachment _______. It is important to keep in mind what your end result needs to be. You are documenting YOUR LIFE, to communicate to someone who does not know you what you did before your disease/accident had an impact on your life.
As you review the MS-specific example of Before and After, you will see that the Before section describes Ms. Magura’s physical activities associated with her job as Vice President of Human Resources for Cascade General, the Portland Ship Repair Yard. Please read Ms. Magura’s example carefully. Note that she discusses the job activities in great detail:
1. When the workday began.
2. What type of activities needed to be performed.
3. What type, frequency, duration, and intensity of interpersonal actions with others needed to be performed.
4. The diversity of activities being performed; the length of each workday; the volume of activities; the requirement for multi-tasking, etc.
5. The number of hours being worked each day;
6. What activities were accomplished after work each day; during the weekend.
In summary, what you are doing is “painting a picture” of your life BEFORE your illness/accident forced you to change your activities. You need to be as specific and as detailed as you can be. What you are doing is explain what your “Normal Daily Living” looked like!
Next, you need to complete the “After” side. Again, read Ms. Magura’s example to see how detailed she is in explaining the impact that MS symptoms have had on her ability to perform her normal daily living activities and the physical, mental, and interpersonal actions of her job.
The Symptom Matrix (Attachment ____________) that you have already completed to document your symptoms to better discuss their impact with your doctor, are helpful when documenting your “After” side of this matrix. Again, be as specific and as detailed as you possibly can. When you are finished, provide the Before and After matrix to someone who knows you and ask them to critique it. Ask them the following question: “If you were an Insurance Adjuster, does this matrix provide enough information for you to get a clear picture of the impact that my illness has had on me; of the level of impairment that the illness has had on my normal daily living?” If the answer is yes, then you are ready to continue. If no, revise the matrix until the answer is yes.
q I have completed my Before and After matrix.
q My matrix adequately describes the impact that my illness has on me, and of the level of impairment that the illness has had on my normal daily living.
Working with your Doctor
The next step is to review the information about what your Doctor needs to know to help you by completing the Physical Capacity Evaluation or Residual Capacity Assessment Form. (See Appendix ------ for the instructions for your doctor. See Appendix ------ for a copy of a letter that you can copy to explain to your doctor what you need for him/her to do to assist you with your LTD application. See Appendix ----- for a copy of a Physical Capacity Evaluation (PCE) Form for your Doctor to use. Finally, see Appendix ---- for a copy of an Insurance Company’s “Attending Physician’s Statement of Disability”.)
Make sure that you have 2 copies of both forms. Complete one yourself, as you see yourself impaired by your illness. Provide them, with the blank forms, to your doctor, along with the information document, and your letter of instructions.
REMEMBER: If your doctor has any differences of opinion about your limitations, make sure that the two of you resolve the differences before the doctor completes the Insurance forms for you.
q You have received back from your Doctor, the completed Insurance forms.
Completing the LTD Application
When you complete the Application, you will also need to complete the Insurance Company’s document called “Claimant Questionnaire for Long Term Disability” (or something like this). See Appendix ----- for an example of a completed document. Ms. Magura placed the questionnaire on the computer, and created a Matrix out of it, so that it can be updated whenever the Insurance Company requests its periodic update.
You now have all of the information needed to complete the LTD application process. Make sure that you have a copy for your records of all of the documents. They should be:
q Insurance Company’s Claimant’s Questionnaire.
q Symptom Matrix.
q Attending Physician’s Statement of Disability (or, Continued Disability)
q Before and After Matrix.
q Physical Capacity Evaluation form.
q Actual Application.
Ensure that you send all of these documents by registered mail, so that you will have proof of receipt. Retain the copy of the receipt with your copy of the documentation.
Documenting Your Inability To Perform “Any Occupation”
By looking into your LTD summary plan description, you should be able to determine how long you can be considered disabled from your own job/occupation. You will also be able to determine when you will need to document your inability to perform any occupation.
What is meant by “any occupation”? Simply stated, this means that your illness has so incapacitated you that you are unable to perform any job that is either full or part time, and which is paid any amount.
To reach this level, your Doctor must agree that you have reached the stage in your illness that you no longer are capable of working. You also must ensure that all of your documentation supports this decision.
You have all of the tools necessary to file for Long Term Disability. Make sure that you keep all of your documents together, so you will be able to find them, when needed.