Again, confirming medical evidence has to be filed. Often, the STD paperwork can be utilized. Letters from supervisory personnel stating the employee can no longer perform the duties are critical.
Many LTD policies have preexisting-conditions limitations. With most policies, there is a two-year window known as the own occupation (ONAC) period. Evidence of continued treatment is paramount to continued receipt of benefits during the ONAC period. Coverage for disability is predicated on the patient being disabled for his or her own occupation. After two years, the any occupation (ANOC) period sets in. The patient must now prove an inability to perform any job and demonstrate that he or she utilized the services of vocational rehabilitation or other retraining program to no avail. It is crucial that the treatment team continue to support the patient.
Employers will contract LTD with an outside insurance company. Many companies provide their own medical experts to review the application. They may also send the file to an outside consultant or even have the patient examined by a specialist. Some carriers hire investigators to monitor patient’s activities.
Leaving a job due to physical/mental impairment is often a traumatic event. The healthcare provider must look at the psychological and physical impact the disability is having on the patient and make recommendations accordingly.
What Is Social Security Disability?
During the two-year ONAC period of LTD, the test to determine the individual’s eligibility for SSDI/SSI is to determine whether there are jobs in the current economy that he or she can perform.
There are five levels in the application and appeal process under Social Security Law (see Table 1):
Table 1: Social Security Disability/Supplemental Security Income Application/Appeal Process
A denial at each level may be appealed to the next level.
Level One:
Initial Application
- Includes patient’s demographic and medical information, and contact information for treating physicians.
Level Two:
Reconsideration
- Generally includes additional information on the patient’s disability.
Level Three:
Hearing Before Administrative Law Judge (AL J)
- The patient hires a lawyer to represent him or her.
- Medical experts may give testimony.
- May take up to two years for the case to be heard by a judge.
Level Four:
Appeals Council
- If the appeal is successful, the case is generally returned to the ALJ for reconsideration.
Level Five:
Federal District Court
- Less than 1% of cases reach this level of appeal.
›› Level One: Initial Application
The patient either visits a local Social Security office or applies by telephone, calling 1-800-772-1213. The patient may also choose to apply online at www.ssa.gov/pgm/disability.htm.
