Key Long-Term Disability Issues for Claimants in 2025: What You Need to Know
Jan. 7, 2025
As we move into 2025, long-term disability (LTD) claims continue to be an essential safety net for employees who can no longer work due to serious illness or injury. However, navigating the complex world of LTD benefits can be challenging for claimants. In addition to the emotional and physical toll of a long-term disability, claimants often face hurdles in the claims process, from disputes over eligibility to confusion surrounding policy terms. Understanding the key issues affecting LTD claims is critical for claimants seeking to secure the benefits they need and are entitled to.
In this blog post, we explore the most significant LTD-related issues that claimants will encounter in 2025, offering insights into the challenges and practical advice on how to address them.
1. The Increasing Complexity of Mental Health Claims
Mental health conditions—such as depression, anxiety, and PTSD—are among the leading causes of long-term disability claims. However, for many claimants, securing LTD benefits for mental health conditions remains a difficult and often contentious process. In 2025, claimants will likely continue to face challenges in proving that mental health conditions meet the stringent requirements set forth in their LTD policies.
LTD policies often place strict limits on mental health coverage, or even exclude it entirely after a certain period. Common exclusions may include limiting benefits to only 24 months for conditions like depression or anxiety, or imposing other restrictions on the availability of benefits.
What claimants should know:
Documenting mental health conditions: It's essential to have clear documentation from healthcare providers supporting the diagnosis and severity of your condition. Keep detailed records of appointments, treatment plans, medications, and therapy sessions.
Familiarizing yourself with policy terms: Understand the limitations and exclusions in your LTD policy, especially if it includes clauses that limit or restrict benefits for mental health conditions. If your policy has such exclusions, be prepared to appeal or seek legal counsel if benefits are denied.
2. Disputes Over "Any Occupation" vs. "Own Occupation" Definitions
One of the most contentious areas of long-term disability claims is the distinction between the "own occupation" and "any occupation" definitions of disability. Many LTD policies start by offering benefits under the "own occupation" definition, meaning you are eligible for benefits if you can no longer perform your specific job. After a certain period—typically two years—this can switch to the "any occupation" definition, which requires you to be unable to perform any type of work for which you are reasonably suited based on your education, training, and experience.
What claimants should know:
Watch for the definition change: Pay close attention to the language in your LTD policy, as the shift from "own occupation" to "any occupation" can create significant hurdles for claimants. If you are denied benefits under the "any occupation" definition, consider whether the insurer properly assessed your ability to work in a different field.
Appeal the decision if necessary: If your claim is denied under the "any occupation" standard, you may be able to appeal the decision, particularly if there are medical or vocational factors that you feel were not properly considered.
3. Challenges with Chronic Illness and Disability Claims
Chronic conditions such as fibromyalgia, multiple sclerosis, and long-haul COVID-19 are becoming more common causes of long-term disability claims. However, these conditions often present challenges in terms of diagnosis and documentation, as symptoms may be subjective or difficult to confirm through traditional medical tests. This can create obstacles for claimants who need to prove their disability.
What claimants should know:
Be prepared for more scrutiny: Chronic illness claims may face more scrutiny because of the complex, often invisible nature of these conditions. Ensure that your medical records clearly document your symptoms, treatments, and the impact on your daily life and ability to work.
Consider a vocational assessment: In some cases, it may be helpful to have a vocational assessment to demonstrate how your chronic condition prevents you from working. This could include evaluations of your job duties, workplace accommodations, and the physical or cognitive demands of your job.
4. Appealing a Denied LTD Claim
It’s not uncommon for LTD claims to be initially denied, and the denial rate for long-term disability claims remains high. Claimants should be prepared for the possibility that their initial claim may be rejected, and the appeals process can be lengthy and complex. Often, LTD insurers deny claims due to insufficient medical evidence, missed deadlines, or misinterpretations of policy language.
What claimants should know:
Understand the appeals process: If your LTD claim is denied, you generally have the right to appeal. Understanding your insurer's appeals process and deadlines is crucial to ensuring your appeal is successful. Many policies require a written appeal within a certain timeframe (often 180 days), so it's important not to delay.
Gather additional evidence: In many cases, an appeal will require submitting new or additional medical evidence. This could include updated medical records, additional opinions from your healthcare providers, or even independent medical evaluations (IMEs) to strengthen your case.
5. Navigating Telemedicine and Remote Evaluations
As telemedicine continues to gain traction, especially after the COVID-19 pandemic, many LTD claims are now being evaluated based on virtual healthcare visits. This trend has led to new challenges for claimants seeking LTD benefits. While telemedicine offers convenience and accessibility, some insurers may question the validity or thoroughness of a diagnosis or evaluation made via telehealth platforms.
What claimants should know:
Ensure comprehensive virtual visits: If your medical evaluations are conducted via telemedicine, ensure that the healthcare provider thoroughly assesses your condition and provides detailed, accurate documentation. Telehealth should not be seen as a substitute for in-person visits if your condition requires a more comprehensive examination.
Request in-person evaluations if needed: If you feel that telemedicine does not adequately capture the full scope of your disability, request an in-person evaluation or ask your provider to document the limitations of remote assessments.
6. The Role of Independent Medical Examinations (IMEs)
In some LTD cases, insurers may require claimants to undergo an independent medical examination (IME) to assess the severity of the disability and determine whether the claimant meets the policy’s definition of disability. While IMEs are intended to be neutral, many claimants worry that the examiners may be biased in favor of the insurer.
What claimants should know:
Prepare for the IME: If you are required to undergo an IME, it is critical to be prepared. Ensure you provide a full and accurate medical history, and document your symptoms and limitations. Keep a copy of all medical records and communications with your healthcare providers.
Challenge biased IMEs: If you believe the IME was biased or did not accurately assess your condition, you may be able to challenge the results. Working with an experienced attorney can help ensure that the IME results do not unfairly impact your claim.
7. The Impact of ERISA on LTD Claims
Most employer-sponsored LTD plans are governed by the Employee Retirement Income Security Act (ERISA). ERISA provides certain legal protections for claimants, but it also limits the ability to sue for benefits under state law. This means that claimants challenging a denied claim must navigate a federal legal framework that can be more restrictive than state laws.
What claimants should know:
Know your rights under ERISA: Under ERISA, claimants have the right to access certain documents related to their claim, including the claims file and any communications from the insurer. ERISA also provides a framework for appealing denials, and you have the right to bring a lawsuit if your appeal is unsuccessful.
Work with an ERISA attorney: If your LTD claim is governed by ERISA, it’s often beneficial to consult with an attorney who specializes in ERISA law. They can help guide you through the claims and appeals process, ensuring you understand your rights and maximize your chances of success.
Conclusion: Taking Control of Your LTD Claim in 2025
As we move into 2025, long-term disability claims remain an essential lifeline for workers who are unable to continue working due to serious health issues. However, the path to obtaining LTD benefits can be complex, with potential pitfalls that can derail an otherwise valid claim. By understanding the key issues that claimants face—such as mental health coverage, policy definitions, chronic illness, and the appeals process—you can better navigate the claims process and ensure that you receive the benefits you deserve.
If you're facing challenges with your LTD claim, consider working with an attorney who specializes in disability benefits to guide you through the process and protect your rights.