When a Worker Is Too Sick to Continue Working Under Any Circumstances
If You Have Disability Insurance through Your Employer
If you are covered under an employer disability plan and become disabled while working, you can apply for disability under that plan. Many companies offer both short-term and long-term disability. Short-term disability is usually for six months—on the theory that a disability may be relatively short and the person can return to work. Sometimes, short-term disability is covered by the employer, and sometimes by an insurance company. So to start, you go to your employer (usually Human Resources) and apply for short-term disability. Some companies offer no short-term disability, so the person can only take sick leave and vacation time during the time period before s/he can apply for long-term disability.
When the short-term disability or waiting period is about to run out, you then apply for long-term disability (LTD). LTD is usually managed by an insurance company—you are actually covered by a long-term disability insurance contract that sets out your rights, responsibilities and benefits—as well as the prerogatives of the insurance company to provide, limit, or terminate your benefits.
The disability standards for LTD policies often differ. Most policies do not require you to be totally disabled (meaning that you can't work at all). Normally, to be accepted under such policies, you will be unable to do your present job, or comparable work requiring your current level of education and skills. You might still be able to do much different and easier part-time work and still be eligible to receive long-term disability benefits. On the other hand, some LTD policies require that you cannot work at all.
Of utmost importance—You should apply for short and long-term disability benefits while you are still on the job. If you think you are about to be fired or laid-off because of your illness, apply for benefits immediately. Your rights to benefits are much clearer if you apply while still an employee. If, for some reason, you have left the job, and need to apply for benefits, you should contact the employer and ask to apply. You may need to check with an attorney. It will be harder to make your claim, but you should definitely do so.
In all cases, the medical documentation provided by your physician(s) as to the diagnosis, severity, chronicity, and disabling effects of your illness is critical to your acceptance for short and long-term disability. Your doctor must agree that you have an illness that prevents you from working under the terms of the disability contract. (You should obtain a copy of the insurance contract.) Your doctor must be willing to document through medical records, office notes, medical letters and reports, and by filling out the insurance company forms, that you are disabled and cannot work. If you do not have a doctor who will do this, you should find a doctor who will. Unfortunately, sometimes a physician becomes unwilling to spend the time or "go out on a limb" to support a disability claim. But usually, if a doctor has known you for sometime as a patient and realizes that you have become chronically ill, he or she will want you to stop working to protect your long-term health.
Normally, the LTD insurance company will want you to see one of their physicians or other health care examiners. You may have to fill out various reports. You may find the effort and the demands of the insurance company taxing, but pace yourself and do your best in making your application. If the company seems not the most friendly or doesn't seem the most reasonable, remember the insurance company is in business to make a profit. But also remember, you have a right to a fair deal with the insurance company. Ultimately you paid insurance premiums.
If at any point you are turned down for benefits, you should immediately obtain the assistance of an attorney who knows how to assist you with the appeal procedures provided by the insurance company and by federal and state law. Often the insurance companies will simply turn people down hoping they will give up. However, if the person applying retains an attorney after being turned-down, then the insurance company may consider the individual's claim more seriously than if no attorney were involved. Sometimes it may take a minimum amount of representation to obtain the insurance benefits on a first appeal.
Individual Disability Policies
Some individuals have themselves purchased a long-term disability policy—a policy of their own, in their own name. If you become disabled under the terms of your policy, you should apply for benefits in the same general fashion as discussed above.
Health Care Benefits under LTD policies
In many cases, individuals receiving LTD benefits can buy Medical Insurance under the federal COBRA law. This allows purchase of the insurance at a group rate, although the entire cost normally must be borne by the individual. After a certain period of time, the COBRA allowance may expire and other health insurance options will have to be pursued.
Long-term Disability Insurance and Social Security Disability
Most LTD policies require an applicant to also apply for Social Security Disability Insurance. Under most policies, if a person is accepted for both LTD and Social Security, the insurance company will deduct the Social Security payment from the monthly amount the company pays. So if you are approved for both, you will not get more than the LTD amount. Usually the LTD amount is higher than the Social Security amount. However, with Social Security, after a two-year waiting period, the individual becomes eligible for Medicare. Some people will say, "Why should I persevere in applying for Social Security if it will only be deducted?" There are several reasons. If Social Security turns you down, then the insurance company may use this as a reason to question your continuing eligibility. Reversing this logic, if Social Security approves your application, you can use the finding of the federal government as an argument to the insurance company of your continuing disability. Also, if you are approved for Social Security disability, then Medicare is a decided benefit if you have no future continuing health insurance.
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