Disability Insurance Claims

Navigating the Claims Process Successfully

If you are trying to decide whether it’s time to file for disability, you need to know what to expect as you go through the claims process. It is critical to develop sufficient evidence to support your claims before you leave the workplace or reduce your work hours. The information below will walk you through the steps of gathering the documentation you will need and the process of filing claims for the most common types of disability policies and programs.

Consulting with a disability lawyer early in the process may increase the chance of winning your case and obtaining benefits. Typically, disability lawyers work on a contingency basis, which means that they do not get paid unless they win your claim. By successfully filing for short-term, long-term and Social Security disability, you will maintain a stream of income even though you are no longer able to work.

Gathering Documentation for Disability Claims

If you are having any difficulty performing your job duties at work, then it is important to prepare the documents that you will need to help prove a claim for disability. While the focus will be different in a short-term or long-term disability claim than it will be in filing a claim for Social Security disability, the most important thing is that you start documenting your professional and personal/medical difficulties now so that you can have proof of them should you need them later. As soon as you suspect you may need to file for disability, obtain copies of your policies and look up the definitions of disability. The documentation you gather will be used to demonstrate that you meet this definition.

Documentation of professional difficulties may include proof of accommodations, excessive absenteeism, productivity and/or performance decline. It may be beneficial to talk with a disability lawyer even at this early stage, especially because this documentation is extremely important and is often quite complicated. A disability lawyer will have extensive specialized knowledge about how best to complete this documentation.

Proof of accommodations may include:

communications from your doctor requesting specific accommodations; and
letters/emails from your supervisor or HR department confirming that accommodations have been requested or approved.

Proof of excessive absenteeism may include:

time sheets (documenting tardiness or absenteeism);
paystubs (documenting a pattern of less than full-time work performed);
attendance records;
disciplinary warnings or actions;
emails regarding absenteeism; and
separation notices which cite excessive absenteeism.

Proof of productivity and/or performance decline may include:

performance reviews;
disciplinary warnings or actions, showing either a decline in productivity or performance;
letters or emails from supervisors documenting problems with performance or productivity; and
separation notices documenting an inability to perform the required duties of the job.

Documentation of personal difficulties may include:

your medical records, which you should regularly review for accuracy with your treating physician
sleep diaries (awake time/alertness/naps);
notes that you may keep regarding your response to medication or treatment;
a history of the medications that you’ve tried;
any changes to your medications;
whether the medications have been beneficial to you;
any problems that you’ve had getting the medication (such as insurance denials or cost);
any documentation confirming your participation in clinical trials.

Be sure to share your documentation of professional and personal difficulties with your treating physician, as this information can serve as a helpful tool that can aid your physician with your treatment. If your doctor includes in your medical record a description of the professional or personal difficulties as justification for a change in treatment, this may prove to be an important factor in a future disability claim.

Filing for Short-Term and Long-Term Disability

Once you realize that your illness is significantly interfering with your ability to work and leading to your disability (as defined by your policies), it is important that you do not wait to file for short- and long-term disability. The benefits you receive will likely be based on your earnings over a defined timeline. If you wait to apply, you may already be working fewer hours, making less money, and therefore having reduced benefits because of your disabling illness. Or your employer may already be disciplining you and planning to terminate your employment, after which pursuing disability income through your employer-sponsored plans can be substantially more difficult.

When you and your doctor(s), particularly the specialist caring for your disabling condition, have decided it is time to file a claim, obtain applications from your Human Resources Department and/or private insurer for short- and long-term disability, as applicable. It is important to determine the timeline to apply for both short- and long-term disability benefits so that the transition from one to the other is as seamless as possible.

Insurance companies’ coverage decisions (determining whether you meet their disability requirements) are going to be based primarily on statements from your treating physician and their treatment notes. As such, most companies will require that your treating doctor submit a form which describes your symptoms, treatment, response to treatment and an opinion as to whether you are able to perform your job.

If you anticipate the potential need to apply for long-term disability, well before the prescribed period for your short-term benefits comes to an end, you should obtain the application and required forms for long-term disability so that you can apply as early as possible with a goal to avoid any interruptions to your financial support. If you do not foresee being able to return to work once the short-term disability ends, then it would be prudent to also file for long-term disability and Social Security disability at that time.

The process for obtaining long-term disability benefits is often long and difficult because insurance companies have a strong financial incentive to deny your claim. Due to the complexity of the process, it is recommended that you consult with a disability lawyer that specializes in long-term disability claims before filing for short- or long-term disability benefits. (Read more about hiring an LTD lawyer HERE.) Typically, long-term disability lawyers work on a contingency basis. (Read more about how LTD lawyers charge HERE.) We are not aware of any organizations or websites that list disability lawyers that specialize in long-term disability. However, you may find a referral through the American Bar Association or through your state’s Bar Association. NOLO also offers some tips for how to choose a lawyer. If you are a member of a Facebook group or support group, it may be helpful to get a recommendation from another group member. If you already know a lawyer who specializes in Social Security disability, then they may be able to refer you to a lawyer who specializes in long-term disability.

Filing for Social Security Disability

The Social Security Administration has its own set of forms and information needed to apply for disability. The Social Security disability claims process is a long and complex one. In filing a claim, one of the first decisions that you have to make is whether to file on your own or to hire a lawyer. Due to the complexity of the process, it is recommended that you consult with a Social Security disability lawyer for assistance with navigating through the process. While it is best to involve a lawyer at the outset, some people choose to file the initial claim on their own and consult with an attorney only if they are denied.

Social Security disability lawyers are not paid through the traditional means of hiring an attorney (paying a retainer and an hourly rate). There is no out-of-pocket or upfront cost to you in hiring an attorney. Instead, the Social Security Administration regulates the payments to attorneys and requires that attorneys be paid on a contingency basis. This means that the attorney has to win your case for you, and that you must be entitled to past due benefits. Past due benefits are essentially the accumulation of back pay that you may earn due to the length of time that it takes for the claim to be processed and approved. If you are entitled to past due benefits, the SSA will withhold 25% of your past due benefits, up to a maximum of $6,000, to pay your attorney, and will pay your attorney directly. Thus, the most that your attorney can be paid is $6,000, and the least that your attorney can be paid is $0. It is to your benefit to consult with an attorney as soon as possible to ensure that you are able to maximize your benefits and that you file the appropriate claim.

Once you have made the decision to pursue a disability claim, you will need to gather a list of the following:

medical providers, addresses and phone numbers;
dates of service and types of treatment;
medications, the reason for taking each medication, dosage and prescribing physician;
a resume or a list of your previous employers, dates of employment, job titles and duties.

While you are not required to secure or submit a letter from a treating physician in order to apply for Social Security disability, you should try to obtain one. You will also gather the documentation regarding your personal and professional difficulties that you collected while working.

Typically, the disability process is a three-step process for most individuals, and could take anywhere from three months to two years to navigate. The first step in the process is to file an initial application for Social Security disability. An application is typically filed either online, in person, or over the telephone at 800-772-1213. SSA seeks to obtain information about your work history, treatment history (including doctors that you have seen and procedures that you have received), medications that you are taking and educational background information. Once the SSA has received your claim, the claim is transferred to a state agency, where records are requested from your medical professionals, hospitals, etc. The state agency has its own team of medical professionals (primarily medical doctors and psychologists) who review your medical records and provide an opinion as to your residual functional capacity (as in, what you’re able to do given your conditions) from a physical and/or mental standpoint. The SSA may also request that you attend a consultative examination with a physician or psychologist, at SSA’s expense, to provide SSA with an independent assessment of your capabilities. The SSA then makes a determination as to your residual functional capacity. The Initial application process typically takes 3-6 months, and you should expect to receive a denial (approximately only 25-33% will be approved at this step). If your case is denied at the Initial level, you have 60 days to appeal the denial.

If you appeal the denial at the Initial level, you move on to the next step in the process, which is to request Reconsideration. At the Reconsideration level, you are providing SSA with updates on any medical appointments or further deterioration in your ability to work. The SSA’s medical professionals again review your medical information and make a determination about your residual functional capacity. This step of the process will take approximately one to six months, and you should again expect to receive a denial at this stage (approximately 7-10% will be approved at this step). If your case is denied at the Reconsideration level, you have 60 days to appeal the denial.

For most people, the last step in the disability process is to Request a Hearing in front of an Administrative Law Judge. An Administrative Law Judge considers all of the evidence of record, including medical records, employment records, diaries, state agency physician and/or psychologist opinions, work history, as well as your testimony about your conditions and how they affect your ability to function on a day-to-day basis. This is the step in the process where most people are approved, as you have the opportunity to explain how your symptoms affect your daily functioning and how effective (or not) your treatment is. The judge also has the opportunity to ask you any questions to better understand your case and your inability to work.

If you are denied at the Hearing level, you have the right to file an appeal with the Appeals’ Council, who reviews your case file and the Hearing decision to determine whether the judge made any errors of significance in the analysis of your claim. If the Appeals’ Council determines that the judge’s decision is proper, then you have the right to file a lawsuit in Federal District Court to appeal that denial.

Additional Resources

Social Security Administration Disability Website. Provides basic information about disability benefits, an overview of the application process, and required information and forms needed to apply. This site includes links to apply online, by phone, or through an SSA office.
IH and Disability: What You Need to Know. Video by Anjel Burgess, a disability attorney, discussing her work advising clients, including idiopathic hypersomnia patients, on their rights and obligations with respect to long-term disability
Narcolepsy and Disability: What to Do When the Writing Is on the Wall. Video by Anjel Burgess for the Narcolepsy Network. The information and advice applies to both narcolepsy and idiopathic hypersomnia.
Sleep Disorders and Your Job – What to Do When the Writing’s on the Wall. Article by Anjel Burgess, Esq.
Emotional Aspects of Disability. Video by Anjel Burgess, Esq.
Differences Between ERISA and Individual Long-Term Disability Plans. An article by NOLO, which provides legal self-help books and information, referrals to lawyers, and more.
Law Help can help patients search for free legal aid programs by state and territory.
Disability Rights Legal Center is a non-profit, public interest advocacy organization that champions the civil rights of people with disabilities as well as those affected by cancer and serious illness.
The Patient Advocate Foundation Resource Library offers articles and videos on many topics of interest to people with severe chronic disease, including disability. To find resources on disability, follow the link to the library webpage and at the very top, use the Category drop down to select “All Resources: In One Spot”. On the All Resources page, use the Educational Topics drop down to select “Disability”.