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"Elimination Period" (EP) and LTD benefits Under ERISA

LTD and ERISA Lawyers: Riverside, Orange & San Bernardino Counties

The "Elimination Period" Definition

Long-Term Disability (LTD) policies typically have an Elimination Period (EP). The Elimination Period is defined as the period starting from the day you first become disabled and continuing for the period noted in the policy. This may be 90 days or 180 days or whatever the policy calls for. 

No Benefits Paid: During the EP, no benefits are paid. You must first complete the EP, as defined in your policy, before any benefits are payable.

Certification of Disability: Your EP starts when your doctor certifies you as being unable to perform your usual occupation (i.e., your job). You must be disabled throughout the EP to be eligible for disability benefits.

Domino Effect: You must remain disabled throughout the EP to become eligible for short-term disability (STD) benefits. You must be disabled throughout the EP and STD to become eligible for long-term disability (LTD) benefits. That's what we call the “domino effect.” 

A Trap for the Unwary:There's a trap here that insurer's often take advantage of in denying LTD benefits. The trap is inadequate documentation of disability in your medical records. Therefore, importantly, your doctor(s) must document your diagnosis, symptoms, and specific functional impairments that prohibit you from performing your job, right from the first day of the EP.

The documentation must be specific. A general statement such as “my patient is disabled from any gainful employment” or “from performing his job,” is conclusory and inadequate. Documentation of disability must be more detailed, and it must be supported by objective information, such as abnormal physical examination findings, abnormal lab testing, or abnormal radiographic or imaging studies.

Example: if you have back pain related to degenerative disc disease and spinal stenosis, your doctor should document that with x-rays and MRI scans, and he/she should also document your impaired functional capacity, noting in the medical records that the most weight you can lift/carry is ___ pounds, and the longest period of time you can sit (in an 8-hour day) is ___, and stand/walk is ___ hours.

If you have a medical condition that is not “structural,” such as chronic fatigue, your doctor(s) should document that with great specificity, including the duration of the fatigue, its frequency, severity, or intensity, and, how often you must lie down and rest, because of your fatigue.

Insurance companies know that this type of detailed medical documentation isn't always done by doctors, who are busy and have a lot of paperwork to deal with, and that allows insurers to deny a disability claim by focusing on the lack of adequate documentation.  

How We Can Help

Our medical experts will review your case and get to know the variations of your condition. This translates into helping the legal experts know how to argue your case and fight for the benefits you deserve.