Get Your LTD Policy Before You File a Disability Claim

Most people file a long-term disability claim without ever reading the policy. They have a one-page benefits summary from open enrollment, or nothing at all. Then the denial letter arrives quoting sections of a document they have never seen.

The policy decides your claim. It defines “disabled,” sets your deadlines, lists what is excluded, and says how much is subtracted from your check. Get it before you file, and read the parts that matter. Here is how.

The benefits summary is not the policy

What employees usually have is a short summary, an enrollment brochure, or a benefits website. Those leave out the language that decides close cases. You want the complete documents:

The group policy or certificate of coverage issued by the insurance company. The certificate is the version given to employees; ask for the full group policy too.
The summary plan description (SPD) if your coverage comes through a private employer. Employer plans governed by ERISA must have one.
Any amendments or riders that changed the policy after it was issued.
Your short-term disability policy, if you have one. Many LTD claims start as STD claims, often with the same insurer.

If you bought an individual policy yourself, you should have received the full policy when it was issued. If you cannot find it, ask the insurance company for a complete copy, including all riders.

How to get it

Start with human resources. Ask your employer’s benefits or HR department for the complete LTD policy and SPD. You do not need to explain why you want them.

If you are covered by an ERISA plan, put the request in writing. Federal law requires the plan administrator to give you, on written request, the latest summary plan description and the documents under which the plan is established or operated. The administrator may charge a reasonable copying fee. If the administrator does not provide the documents within 30 days of your written request, a court may order it to pay a penalty of up to $110 a day. That penalty is up to the judge, but the rule gives your request real weight.

The plan administrator is usually your employer, not the insurance company. The SPD names the administrator and its address. Send the request there, and keep proof of when you sent it.

If you are no longer working, the same rights apply. You can still request the documents from the plan administrator.

What to look for when it arrives

You do not need to read every page. Find these eight things and mark them.

The definition of disability. Own occupation, any occupation, or both, and when it changes. More: Own occupation vs. any occupation.
The elimination period. How long you must be disabled before benefits start, often 90 or 180 days.
The benefit amount and the definition of pre-disability earnings. Many policies pay a percentage of base salary only, not bonuses or commissions, up to a monthly maximum. Check what counts.
Offsets. What gets subtracted from your check: Social Security disability, workers’ compensation, state disability benefits, some pension payments. Most group policies require you to apply for SSDI. More: Why your insurer makes you file for SSDI.
Limitations and exclusions. Mental health limits, limits on conditions based on self-reported symptoms, substance-related exclusions, and any pre-existing condition exclusion. A pre-existing condition clause usually looks back at treatment you received during a set period before your coverage started.
Claim deadlines. When you must give notice of the claim and when proof of loss is due. Missing these can sink a claim before anyone looks at your medical records.
Discretionary authority. Language giving the insurer “discretion” or “discretionary authority” to decide claims. In an ERISA case, this can change how a court later reviews a denial. More: Why ERISA favors insurance companies.
The deadline to sue. Many policies set their own time limit for filing a lawsuit, and it may start running earlier than you expect.

While you are gathering documents, add two more: your written job description, and recent pay stubs showing your earnings and any premium deductions.

Why this matters before you file

The claim forms ask you, your employer, and your doctor to describe your condition and your job. If you know your policy’s definition of disability, those answers can address the right question from the start. If your policy uses an own-occupation test, your doctor should explain why you cannot do the specific duties of your occupation. If you already know a mental health limitation applies, you and your doctor can make sure every condition that keeps you from working is documented, not just one.

You also avoid surprises. It is far better to learn about offsets, earnings caps, and pre-existing condition exclusions from the policy than from a letter after the fact.

Sample request letter

Adapt this to your situation. For ERISA plans, send it to the plan administrator named in your SPD. Keep a copy and proof of mailing or delivery.

[Date]

[Plan administrator’s name and address, from the SPD]

Re: Request for plan documents Participant: [Your name] Employer: [Employer name] Plan: [Name of the long-term disability plan, if known]

I am a participant in the long-term disability plan named above. Under ERISA section 104(b)(4), 29 U.S.C. § 1024(b)(4), I request copies of the latest summary plan description, the group insurance policy and any certificate of coverage, all amendments and riders, and any other documents under which the plan is established or operated. Please also send the same documents for any short-term disability plan in which I participate.

Please send the documents to the address below. If there is a charge, tell me the amount before sending.

[Your name, address, phone, email]

What to do now

Ask HR for the full LTD policy, SPD, and STD policy today.
If they do not arrive promptly, send the written request above to the plan administrator.
Mark the eight items above, especially your definition of disability and claim deadlines.
Call us before you file if anything in the policy is unclear.

Get Your Policy Before You File