Introduction
If you are unable to work due to a disability, you may be eligible for short-term (STD) and long-term disability (LTD) insurance benefits. The application process for disability benefits can be complicated and time-consuming, and it can be difficult to know what to expect. In this article, we will discuss the steps you can take to increase your chances of having your claim for disability benefits approved. We will discuss how to prepare for the application process, what documents and information you will need, and tips for navigating the application and appeals process. By following these, you can increase your chances of having your claim for disability benefits approved.
Getting disability benefits approved for someone with long COVID can be especially difficult because the symptoms can vary widely from person to person, making it difficult to prove that the disability is severe enough to qualify for benefits. Additionally, the medical evidence required to prove a disability can be difficult to gather for a condition that is still relatively new and poorly understood. Long COVID symptoms may improve or worsen over time, which can make it difficult to prove that the disability is ongoing and long-term. This article will provide guidance on how to increase your chances of having your claim for disability benefits based on long COVID approved, based on the lessons we’ve learned by helping other people in similar situations.
This article builds upon foundational information about disability benefits that we have published on our COVID-19 and Disability Benefits page.
Your Insurance Policy
The first step of applying for disability benefits is to learn about your disability insurance policy to find out what is covered and what documentation is necessary to apply for benefits. You may need to contact your employer’s human resources department to obtain a copy of your policy, commonly known as your “Summary of Benefits and Coverage,” or “SBC.” If you need help obtaining a copy of your SBC from your employer, you can contact the Employee Benefits Security Administration (EBSA).
There are a few provisions of your policy that you should pay particular attention to:
- The policy’s definition of disability;
- Any coverage exclusions and limitations; and
- The number of times a claim can be appealed and the process for filing an appeal.
Make sure you understand these provisions before you file your claim. For your claim to be successful, you will need to satisfy all of the policy’s criteria, so you’ll want to have a good mastery of these provisions.
Benefits Application
To apply for disability benefits, you will need to provide information about your medical condition, including test results, medical records, and a statement from your doctor. Additionally, you will need to provide information about your employment history, including details about your job duties, any modifications you need to perform your job, and any accommodations you may have received for your disability.
Once you have gathered all the required documentation, you will need to fill out the appropriate forms and submit them to the insurance company. It is important to make sure that all forms are filled out accurately and completely, as any errors could result in a delay or even a denial of your claim.
Some general guidance for your claim:
- You should try not to use “long COVID” to describe your disability, because it represents a collection of different symptoms, with varying severity. Instead, try to describe the specific symptoms you are experiencing and how they limit your ability to work or prevent you from working altogether.
- Do not rely on ambiguous terms like “fatigue” and “brain fog” when describing your symptoms. More precise language for these symptoms is “post-exertional malaise,” “exercise intolerance,” “cognitive impairment,” and “executive dysfunction.”
- Visiting a specialist will help you document your symptoms more clearly. A specialist will also be able to include the results from more complex diagnostics, and their interpretation of those results, in your medical record. Appropriate specialists for diagnosing long COVID symptoms include cardiologists, rheumatologists, pulmonologists, psychiatrists, neurologists, and ophthalmologists, among others.
- Providing medical documentation from a specialist will make it more difficult for the insurance company to deny your claim.
- The following diagnostic tests may be helpful to submit with your claim: a full physical examination, Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), Thyroid Stimulating Hormone (TSH), Cytomegalovirus (CMV) antibody, Epstein-Barr virus (EBV) antibody, Human Herpesvirus-6 (HHV-6) antibody, Chest X-Rays, Pulmonary Function Tests (PFT) neuroimaging such as Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) scans, Cerebrospinal Fluid (CSF) analysis, lumbar puncture, Positron Emission Tomography (PET), Single Photon Emission Computed Tomography (SPECT), Visual Evoked Potential (VEP) testing, Enzyme-Linked Immunosorbent Assay (ELISA), Electrocardiogram (ECG), Echocardiogram, Electroencephalogram (EEG), Electromyography (EMG), Cardiopulmonary Exercise Testing (CET), V02 Max testing, and neuropsychological testing.
- Do not rely on medical documentation provided by a naturopathic doctor, homeopathic doctor, or alternative medicine practitioner to support your disability claim. Some disability programs and policies prohibit this documentation from being considered. Always try to provide medical documentation obtained from an M.D.
Once your claim is submitted, you will need to be patient as the insurance company reviews your claim. The insurance company may require additional information or documentation before making a decision. Be sure to answer any questions promptly and to follow up with the insurance company if you have not heard back after a reasonable amount of time.
Claim Adjudication
Once the insurance company receives your claim, they will determine whether you are eligible for benefits. Your claim for disability benefits may be denied for various reasons, and it is common for this to happen with the initial claim. People with long COVID commonly have their claims denied for one of the following reasons:
- They did not meet the policy’s definition of disability;
- They did not provide enough medical documentation; or
- They did not follow the policy’s required procedures.
If your claim is denied, do not panic! You will have adequate time to understand the insurance company’s reasoning and, if you disagree with it, to appeal their decision. In a denial letter, the insurance company will describe its rationale and the company will cite specific parts of your policy that govern its decision. Before you file an appeal, make sure you understand the grounds for denial and what you need to do to overcome the insurance company’s decision.
Some disability insurance policies allow you to appeal the decision multiple times, while others only allow you to appeal once (called an “administrative,” or “internal” appeal) before you must go to court to challenge their decision. Depending on your jurisdiction, you may not be able to submit new documentation to support your disability once you go to court, which means you may only get one opportunity to provide the right medical documentation.
Appealing Your Claim
Before appealing your claim, you can request your case file from the insurance company, which includes all the documentation the insurance company reviewed when making its decision. Be sure to make note of any relevant documents that are missing and plan to include those documents with your appeal.
When appealing your claim, you will need to provide a written statement rebutting the insurance company’s reasoning for denying your claim. With your appeal, you will have the opportunity to provide additional medical documentation to support your claim. If your claim was denied for not providing enough medical documentation, you should begin scheduling appointments with specialists who can support your appeal.
The written statement that accompanies your appeal does not need to be complicated, but it should clearly describe why you are eligible for disability benefits under the terms of the policy. If there are any flaws in the insurance company’s reasoning or facts that are misrepresented, be sure to point those out in your appeal letter. If you need help writing your appeal letter, consider asking your family and friends to help. If you don’t have people in your personal support network who can help, or if you need more assistance than they can offer, you can request help from an attorney through our Pandemic Legal Assistance Network (PLAN).
Conclusion
The process of filing a claim for disability benefits can be intimidating, especially if you are applying for benefits based on a condition as new and poorly understood as long COVID. However, with careful preparation and understanding of the insurance policy, you can increase your chances of having your claim approved. By understanding your policy, gathering all of the necessary documentation, and appealing the decision if necessary, you can present a strong case for your disability benefits.
