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stinger66sstinger66 Posts: 67
edited 06/11/2012 - 8:46 AM in Health Insurance Issues
So I get a call the other day from my LTD carrier through my former employer telling me that my LTD will stop after two years? They are telling me that they feel that I can do sedantery work even though from day one of my surgery my Dr. has said no. Every note from him say that I cannot even do any kind of work at all due to uncontrolled pain.

Can LTD do this. I was approved for ssdi one year ago & have not heard anything from them.

Anyone that can help thanks !!!



  • Don't you have the opportunity for an appeal?
  • I'm on LTD and they're making me apply for my work and government pension but as far as the policy goes they have to cover me until I get my pensions or supplement them. You may need to get a Lawyer to read the LTD contract for you. When talking with my union they directed me to a website that supplies free consults for disability lawyers. Unfortunately I'm in Canada so it may be different for you. I hope you can find a good lawyer. It's all about the money for them so you have to fight for your rights. I hope you get some answers, it's terrible to have paid for these benefits and not feel secure about where your funds are coming from. Take care and hope you get some answers. Charry
    DDD of lumbar spine with sciatica to left hip,leg and foot. L4-L5 posterior disc bulge with prominent facets, L5-S1 prominent facets with a posterior osteocartilaginous bar. Mild bilateral foraminal narrowing c-spine c4-c7 RN
  • SpineAZSpineAZ WiscPosts: 1,084

    First I'll give you some general LTD information, then some examples, then some stuff for you to consider:

    Most LTD policies are structured so that the first two years of LTD is based on if the claimant can do his/her own occupation or what is called "Own Occ". After 24 months under Own Occ, further continuation of benefits under LTD now requires that the person meet the "Any Occ" definition of disability in the policy. Any Occ refers to if the person can do any occupation "any occ" for which he/she is reasonably trained, educated, experienced and able to do given your disabling conditions. {Just a note that policies differ, some have 12 month Own Occ, 36 month, etc).

    This does not mean that if someone were a Senior HR Manager at a Law Firm and were making $250,000/yr that they can expect that person to work as a receptionist for $22,000/yr. But it does look at the claimant's full work history, education history, earnings history, current medical and psychological conditions, medications, etc.

    EXAMPLE 1:

    33 year old OR nurse has an accident and her lower leg is amputated. She is disabled from her Own Occ as she can not be a nurse in the OR.

    Nearing the end of the 24 month Own Occ period the LTD company evaluated the claim to see if there are other viable nursing jobs she can do AND what her current condition is, medications, treatment, etc.

    There are nursing jobs at insurance companies, law firms, etc, which are totally sedentary. These nurses often work on medical or disability claims and don't do any actual patient care. The LTD carrier may find that she's reasonably able to perform these other nursing occupations and thus not disabled under Any Occ.

    OR, she's been fitted successfully with a prosthesis and medical information shows she has no walking or standing limitations based on her success with the prosthesis and rehabilitation. The LTD company is likely to find that she does not meet the definition of disabled under Any Occ.


    EXAMPLE 2:

    33 year old man with a GED has worked in a copper mine in a very physical occupation for 15 years. He has a car accident resulting in multiple broken vertebrae in his back and a fractured pelvis. He is disabled from his Own Occ.

    As the 2 year mark approaches for Any Occ the claim analyst, and perhaps the Vocational Rehab staff at the LTD company, review the claim and find that he has significant physical limitations and due to limited education would not be a viable candidate for any sedentary occupations. His claim is likely continued under Any Occ.

    EXAMPLE 3:

    42 year old man who has a BA in Sociology worked as an insurance sales person making $50,000/yr for 15 years. He was then laid off and he took a job as a hospital security guard making $30,000/yr. After 3 years on that job he has a massive heart attack and 2 bypass surgeries.

    His claim is approved under Own Occ. Occasionally the LTD company requests medical updates and finds no improvement and no expected improvement along with permanent cardiac limitations.

    As the Any Occ period approaches all of the medical and vocational information in the claim is reviewed. His physicians, and the nurse reviewer at the LTD company, all agree that he can not return to any type of work that requires extensive standing, walking, lifting, or any prolonged physical exertion. But his cardiac capacity is such that he is able to sit for unlimited periods, take light walks, and has no need to remain totally sedentary. He also has no additional disabling conditions. The Vocational Rehab on staff at the LTD carrier find that there are jobs at insurance companies as "Inside Sales" which do not require physical strain, travel, etc. And the average starting salary for the jobs are $32,000/yr. His LTD would likely be terminated at Any Occ since he is physically able to do an occupation available in the general economy, for which he has sufficient experience and education and which will also provide him reasonable wages.


    EXAMPLE 4:

    61 year old woman who was working as a receptionist goes out of work on STD, then LTD, for a multi level lumbar fusion (L4-S1). The surgery does result in a fusion but remaining pain requires that she be on prescription pain medications on a long term basis. She is approved for Own Occ due to the long rehabilitation and extensive medications.

    When the Any Occ period rolls around the woman is nearing 63 years old. She is on less medications but requires a cane to get around her home and has given up driving due to the effect of the medcations on her as well as developing hip pain which her doctor's say now requires a hip replacement within the next few years.

    Her claim is approved at Any Occ both based on her medical condition, expected surgery for a new condition that wasn't claimed when LTD began and due to her advanced age. She applied for SSDI after her LTD was approved, and she was approved for SSDI on first appeal.

    Before they will close out your claim they will review all medical records, your employment and education history, etc. If they find that they will terminate LTD at Any Occ they will send you a detailed letter with specific information as to how they arrived at that decision. Included in the letter will be information about how to appeal, the time line in which you must do so, etc.

    Thus it's important to share with then ANY AND ALL conditions which may preclude you from going back to work. [For example, I'm 44 and have a moderate bilateral hearing loss which hasn't adversely affected me. Vocationally it limits me from working in noisy environments, call center jobs, etc. I've already notified LTD of this and my SS attorney as well]

    Very often during LTD the claimant may develop other conditions but since they are receiving un-interrupted LTD they don't think to share any new medical iformation with the LTD carrier.

    If you feel you are unable to return to any type of work you'll need to meet with each of your physicians and discuss in detail. Are there medications you are on which would preclude you from certain jobs? Have you developed other severe physical or psychological conditions while you have been on LTD? Are you seeing physicians for this that LTD may be unaware of, etc.

    Be sure to get a copy of the exact LTD plan under which you are covered. You want to be able to read the exact definition of disability they use for Own Occ and Any Occ.

    Keep in mind it's not the doctor saying "no, this person can't work". What is required is medical records to accompany the physician's opinion to substantiate that you are not able to perform any type of work.

    Did your LTD company have you apply for SSDI? If so what is the status? Often, if they do and they provide the attorney, then it's an indication they expect the person to possibly be disabled under Any Occ when the time comes.

    Let me know if you have any questions.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
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