Disability Claims Solutions

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To begin this year with a more knowledgeable perspective, I put together the template below to guide you when reviewing your Group LTD Plan. This template will be particularly helpful to new claims as well as ongoing claims.

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Based on your date of your enrollment in the LTD Group Plan, and date of hire, determine your Effective Date of Coverage found on the first page of your Plan..

If your employer has multiple locations for a single parent company, check your Plan for the location you are currently working in to make sure it is listed. Make sure your coverage is included at your specific location.

If you missed the annual enrollment for LTD and have been asked to fill out “Evidence of Insurability”, make a special note to sign up on time the following year. This is called “Evidence of Insurability”. Contact the HR rep to make sure you know when and where the next annual enrollment will take place.

Assuming a yearly date of disability and a timeline, draw out any potential pre-existing condition period using the “Pre-Existing Condition” definition in your policy. You should calculate your pre-existing period before going out on disability for any reason, and if necessary, wait the 12 months before filing any claim.

Determine what “Class of Eligible Employee” you are in, and the number of hours you must be working just prior to your date of disability in order to be eligible for benefits.(Minimum benefit requirement provision)

Keep copies of all your payroll stubs and prior year’s W-2. You may need this information to determine your pre-disability earnings. Find the definition of “Earning” in your Plan and figure your BME (Basic Monthly Earnings) defined as what you were making before you became disabled. Use the Plan document as the basis for your calculations.

Once you have the BME figure calculate 80% of this figure. If you return to work part-time, and are eligible for “Residual Earnings” you may not earn in excess of this figure, adjusted for inflation. (Indexing) Receiving earnings in excess of the 80% will result in a claim denial.

Locate the definition of “Elimination Period” in your Plan and determine whether you are allowed to work or not work during the EP. If your policy says you may NOT work during the EP, and you return prematurely, you may not receive any benefits at all.

Read the “Definition of Disability” provision in your policy. In fact, read it several times and make sure you understand completely under what circumstances you may be considered disabled.

Go online to http://online.onetcenter.org/ and the DOT and download a copy of the “Occupational Description” of your material and substantial duties. You may not get an exact description, but choose the occupation the closest to your own. These occupational descriptions will tell you what your “material and substantial duties “are.

<p class="just"Locate other “Add In” provisions in your Plan and estimate the monetary value of these benefits. Examples include COLA’s, Rehabilitation, Child Care, Disability Plus Riders etc. Using your calculator, figure your estimated gross monthly disability benefit. If your policy contains a COLA provision, calculate at least a 5 year schedule of benefits.

Contact Social Security and ask for a determination of your eligibility and amount of both Primary and Family Social Security. (SSDI) You can fill out a form and ask social security to provide you with this information at any time. If you have not worked the required number of “quarters” for SS or SSDI, you should know about it before you are sick or injured. You may also go online to ssa.gov and obtain the same information.

Determine whether your Plan is non-integrated (does not allow offsets) or integrated. Check the provisions specifically dealing with social security and determine whether the offset will be only for amounts awarded to you (Primary SSDI), or Primary and Family.

Obtain an application for FMLA and have it on hand in case you need it. This application can be obtained from your employer.

Examine your policy provision for all of the “Take Backs” listed in your Plan and calculate your “net benefit.” This is your bottom line. Gross Benefit + Add Ins – Take Backs = Net Benefit. This is an important figure, and it should be calculated each year as your salary and work circumstance change.

Check the Glossary in your policy to determine if it gives a specific definition of “Gainful”. If it does, and reading your Plan provisions, calculate the likely figure the insurance company will use to determine if any occupations identified during a TSA will be gainful.

Make a contact list of all of your state resources, i.e. Human Resource Department, Food Stamp Division, Medicaid, Utility Assistance, WIC programs etc. Obtaining this information when you are not feeling your best is quite a chore. Be prepared, and make a contact list long before you need the information on it. Include the contact information for both the Insurance Commissioner and the DOL on this list.

Ask questions. If you have questions after completing the above worksheet, contact your HR benefits representative or other trusted resource for the answer, and don’t wait. Check the Glossary in this book for definitions you may have missed.

If you are able to return to work part-time, begin an earnings record or journal to keep track of your monthly earnings and the computations of your earnings loss ratio. Contact your claims handler and request a copy of the insurance computation spreadsheet so you can verify the accuracy of the checks received, and the 20% earnings ration (or 3-year averaging as the case may be.)

All claimants should be informed and ask questions before they need to apply for benefits. YOU BET! Your disability insurer can only take you by surprise if you put off knowing the provisions of your Group Plan and what benefits you are entitled to. Start off the claims process with a good review of your Plan, or review at the beginning of each new year to refresh your knowledge of what you are entitled to.