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Filing a Claim for Disability Benefits

By Jacques Chambers

(click here to download pdf)

There is more to filing a claim for disability benefits, whether it is short term or long term disability, than just filling out some claim forms. Unlike government programs, which are bogged down in bureaucracy, insurance companies have a financial incentive not to pay benefits. Therefore it is imperative that you be thorough and careful when filing a claim.

Filing a claim for disability benefits will require some time and effort. While the insurance company is “happy to pay all qualified claimants” it often appears their idea of “qualified” is fairly limited. When you file a claim, the insurance company assumes you are not disabled and it is up to you to prove you are.

You start the process by obtaining a claim form or claims packet. Where you get these forms depends on the type of coverage you have:

Employer Provided Long Term Disability:  The claim forms for this coverage must come from your employer, or your employer’s hired administrator. While you may not want to get the LTD claim form when first leaving work, you should allow at least two months for the claim to be processed.

Individual Disability Income or Association Disability Coverage: Obtain these claim forms from the same place you bought the coverage. It may be an insurance agent or the association office or call the insurance company directly and request “the forms to file a claim for disability benefits.”

Some companies call it a claim form; some call it a claims kit. Either way, the claim form will consist of several parts:

Employer Portion of the Claim Form
There is a portion of the form for the employer to fill out.  Even if your plan is an Individual Disability policy that you purchased yourself, they will usually ask for some information from your most recent employer or yourself if you were self-employed.

This portion of the form is primarily to get the basic facts about your employment: date of hire; last day worked; job title; salary; etc. They will also usually ask the employer to submit your job description as well.

If at all possible, ask your employer to complete the form first and send it to you so you can send it to the insurance company with the other portions of the form and the medical evidence. Many employers will want you to complete your portion and the doctor’s portion and send it to them for filing with the insurance company. The problem with this is you don’t know how long it will sit around their office before the claim is submitted. A compromise is to request a copy of the form with their portion completed when they submit it to the insurance company.

Physician Portion of the Claim Form
There will be a section, usually two or three pages, which your doctor needs to complete. Hopefully, your physician has filled these out before and knows how to complete them. Some points you may want to, tactfully, suggest to the physician:

  • While the doctor’s opinion on whether or not you are disabled is interesting and may even be requested, the insurance company must have the documentation that supports that conclusion. Just the doctor’s opinion not sufficient to get the claim approved.
  • The more the doctor can document the presence of symptoms with laboratory tests and other “objective” methods, the better.
  • For “subjective” or “self-reported” symptoms such as pain and fatigue, it is helpful for the doctor to confirm that such symptoms are “expected” with the diagnosis and lab results, confirm their presence, describe their severity, and hopefully, refer to the comments on the symptoms that are in the office notes.
  • It is helpful if the doctor has an idea of the type of work you do and can note certain job duties that you can no longer do because of your symptoms.

The physician may request your input in the document. You can help by pointing out the symptoms you have and the job duties you can no longer do. Make sure the physician(s) return(s) their portion of the claim form to you once it is completed.

Claimant (Your) Portion of the Claim Form
The final portion of the claim form is the portion that you fill out yourself. The most important part of this section is listing the names and addresses of the medical providers that have the medical records that the insurance company will need to review. List complete names, mailing addresses and phone numbers. If you don’t know them, look them up, as the insurance company will contact these providers.

There will also be questions about your education and work experience. This will be used to help determine what “suitable” occupations you may be able to perform. Be thorough and accurate here as well.

Fill out the remainder of the form as completely and accurately as possible, however, don’t get overly concerned. Your statements alone won’t decide the claim, but you can explain how the symptoms affect your ability to function. When possible emphasize the symptoms you experience that prevent you from working and mention which tasks they prevent you from performing.

Don’t be intimidated by small blanks on the form. It is not uncommon for the company to ask you why you can’t work, then leave only room for one line of information. If you don’t have enough room to write your answer, simply say “See attached” and attach extra sheets of paper with your answers. Be sure to label each answer carefully. Also put your name and Social Security (or ID number) on each page.

Don’t stress on this portion of the form. Your claim will not be decided on the basis of your answers on the claim form, so don’t worry that it has to be perfect. Answer all the questions completely and honestly. Focus on the symptoms and your inability to work and it will be fine.

Should you type the form on computer? Using a computer to answer the questions on the claim form can make for well-edited, easy-to-read information. It is easy to make corrections and add information. It also is easy to cut and paste the information to other questionnaires or other forms, and it gives you a record of what was submitted.

However, there is a drawback to using the computer for this. It can look too neat, even professional, especially if you are computer-proficient. While the quality of the claim form wouldn’t be listed as a reason for denying your claim, it can affect the “initial impression” of your claim by the Representative, causing him/her to look at the rest of the evidence more critically.

If you decide to use a computer to type your answers, you should note on the form how long it took you to complete the form, any problems you encountered, plus any help you received.

Authorization to Release Information
There will also be a form for you to sign which authorizes the release of information to the insurance company. While it is primarily to give the Claims Examiner access to your medical records, many of these releases are extremely broad, allowing them to obtain information about your finances as well. It will sometimes even authorize them to share information with your employer.

It is important that you read this authorization thoroughly before signing it. If you disagree with some of the provisions, you may wish to strike those sections from the release and initial the strike-outs. If you do alter the release in any way, it is important that you write a cover letter with the release explaining what you have done and offering to provide any specific information in those areas upon written request to you.

It is your choice to make changes on this form, but there is a risk to altering it. Insurance companies have been known to stop processing the claim until they get a signed, unaltered release. Others will state on the release that any changes void the entire document. The insurance company has leverage in this since they can simply stop processing the claim maintaining your lack of cooperation.

Job Description
It is important that a job description of your occupation be included with the claim whether they request it or not. Many job descriptions maintained by employers no longer accurately reflect the job as it must be performed, or the description is so generic it is difficult to tell just what the job tasks entail.

Get a copy of your job description from your employer. Carefully review it with your employer to make sure it accurately reflects all the major tasks of the job. Make sure physical requirements such as travel, lifting or walking are included. If the job requires meeting deadlines, managing staff, or other tasks that can cause high stress, make sure they are noted as well. If there is no written job description, you should create one.

Sending in the Claim
When possible, assemble all the completed portions of the claim form, photocopy them and mail them directly to the insurance company. Follow up a week or two later to make sure they got it and get the name and number of the claims adjuster handling your claim so you can help them obtain all the medical records they will need to process the claim.

 

Confused about applying for disability? Click here

[Jacques Chambers, CLU, and his company, Chambers Benefits Consulting, have over 35 years of experience in health, life and disability insurance and Social Security disability benefits. For the past twelve years, he has been assisting people with their rights, problems, and other issues concerning benefits and disability. He can be reached at jacques@helpwithbenefits.com or through his website at: http://www.helpwithbenefits.com.]



Copyright, (August, 2006) Hepatitis C Support Project / HCV Advocate www.hcvadvocate.org. All Rights Reserved. Reprint is granted and encouraged with credit to the Hepatitis C Support Project


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