Everyone hopes they never have an illness or injury that prevents them from working and supporting their family. Unfortunately, we know the reality is that bad things happen, and sometimes sudden illness or injury is unavoidable. This is why we should prepare with disability insurance and understand the disability claims process. The CDC reports that 26% of adults in the US have some type of disability. They define disability in this way:

“A disability is any condition of the body or mind (impairment) that makes it more difficult for the person with the condition to do certain activities (activity limitation) and interact with the world around them (participation restrictions).”

What is Disability Insurance?

Disability insurance replaces part of a person’s income when they are unable to work due to an illness or accident.  There are two types of disability insurance:

  1. Short-Term Disability (STD) insurance – As the name implies, this covers an income loss for a shorter period (usually for 3-6 months), but it could cover up to a year depending upon your policy. Benefits typically start after a waiting period of 1-14 days from the start of the disability.
  2. Long-Term Disability (LTD) insurance – This coverage usually starts once STD benefits are exhausted. With LTD insurance the wait for benefits to start is typically much longer (at least 6 months) and is governed by the policy.

 

As noted above, the individual insurance policy/plan mostly dictates how the benefits are delivered – such as when benefits start, how long they last, the definition of disability, and the amount of income to be replaced.

One very important factor is your policy’s definition of disability. There are 2 main ways to define a disability:

  1. “Own Occupation” is a disability that prevents you from performing the job you were performing when you became disabled.
  2. “Any Occupation” is a disability that prevents you from performing any job.

How does the Disability Claims Process work?

Insurance and claims management companies employ claims professionals to administer disability benefits. Typically, your healthcare provider sends medical records to the claims professional managing your claim to support the disability. The healthcare provider also gives an estimated length of the disability.

The claims professional reviews the medical records and makes a claim decision based on evidence-based guidelines – such as Reed MD guidelines or the Official Disability Guidelines (ODG) – for expected length of disability based on the diagnoses.

When a claim decision is complex – due to the estimated length of disability being outside the norm, claimant co-morbidities, or behavioral health issues – the claims professional may refer the case to a clinician to further assess the claim and get a clinical recommendation prior to making the claim decision. The clinician (often a nurse reviewer) provides a more in-depth review of the medical issues that either support or do not support the claimed disability. Some of the items that a nurse reviewer analyzes are 1) the need to request more information from the treating provider, 2) how the patient’s co-morbidities may impact the length of disability, focus on functionality, restrictions and limitations, or 3) if the current treatment is consistent with the severity of the condition.

The role of nurse reviewers is crucial in the disability claims process, both for the patient and insurance/claims management companies. If you’re part of an insurance or claims management company and need nursing expertise, Shearwater Health is the expert in assisting claims professionals with complex claim cases. Contact us to learn more.