Private Long Term Disability coverage vs Social Security Disability

I read quite a few stories here about how dire Crohn's can get and that some people applied for Social Security Disability. My company (a large employer with more than 10,000 employees) offers Long Term Disability coverage in addition to short term disability coverage. When I pay a very small premium each month, I can get up to 60% of my regular pay if I become long-term disabled.

From what you experienced/heard, is it easier or more difficult to receive private long term disability benefits (from employer) than social security disability? I have the impression that private long term disability benefits are more generous. But I am not sure how difficult it is to apply one? Thanks. Can you have both, I mean for people in the U.S.?

Private will pay more, and I assume for how hard it is to apply would depend on the company, but from what I hear most arn't too bad about it. Like Tag-a-Long said they are not forever though. I believe you could apply for social security after private disability runs out, though.

Under 26 weeks, it is said employees can be covered under Short Term Disability with full pay. From 27 weeks up to 2 years, employees can be covered under Long Term Disability with 60% pay, if I cannot do my regular job. After 2 years of long term disability, "you are considered disabled when it is determined that due to the same sickness, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience." If I can prove that I cannot perform any "gainful work" after 2 years of disability, I may be eligible for 60% of pay.

I have never tried to apply this benefit before. My question is: is this real for people with CD? How can I prove that I cannot perform "any gainful occupation" unless I am completely paralyzed?

Paul you are right, the first 26 weeks is short term disability, then after that is the long term disability that pays 60%. My understanding is you can stay on that until about 2 years when you will then need to apply for SSDI. Good luck!

There are 2 types of disability coverage, aside from social security, but first, this will probably be very boring to read, just to warn you upfront. ;)

The first is through a private policy that you pay for yourself out of pocket. These are known as Cadillac policies in the insurance world, and they are quite difficult to get. You will need to pass several health screens, and you will need to personally describe any health problems you have in detail, so the company can decide if they want to offer you coverage or not. If you omit something, and they discover it after you file a claim, there is no problem, they will just deny the claim, and refund all your premiums, it is that serious.

The good news here is, you can sue the insurance company if they cut your benefits off, and you can sue them for punitive damages too. They tend to treat these policies with the utmost respect and care. Sometimes you can get coverage if you have a health problem, the insurance company will add what is called a Rider onto the policy, it will exclude the condition listed, for x number of years, once you get past that period, you are covered. I have NEVER seen someone with crohn's disesase qualify for this type of policy. Even someone with mild CD, who has completed medical school, and has not flared up in years, will simply not qualify for this policy. If you are in excellent health, and young, you can qualify for this type of coverage. I suggest these to everyone I know who is in good health, with a good career. To date, I have not convinced one person to sign up for this type of coverage, they just don't feel that turning loose of 150 bucks per month is worth it, and besides, they have excellent insurance through their work, they already have disability coverage........... Which brings me to what they actually do have.

The next type is much more common. It is group ERISA coverage. That term ERISA is important, because it is what governs the policy. An older law designed to govern pensions, now governs this particular insurance policy. The good part about this coverage is simple, anyone can get it, all you need to do is go to work for an employer who offers it, and sign up. Yep, anyone reading this right now, you can get this coverage, but you will have to work for it, you will have to jump through a few hoops, before you can actually file a claim, and get it paid.

Sometimes you pay for some of this policy, sometimes the employer does. Keep in mind, whoever pays the premiums here, also gets to use it for tax purposes. If you pay 50% and the employer pays 50%, should you file a claim, you will only be taxed on 50% of the benefits you receive. If the employer pays the full premium, you will be taxed on 100% of the benefit you receive.

These policies often, well they ALWAYS, have a pre-existing clause, you may need to work for the employer for xx number of months before you are covered, if you currently have crohn's disease. Each one of these policies can be different. Different waiting periods, longer times in own occupation, less months with the pre-ex clause.

Anything you can think of, they are 2 steps ahead of you here. The only way to get past the pre-ex is to work for the employer for xx number of months, just like it says in the policy. All the details about this policy will be listed in something called the SPD, summary plan description. You can request this document from the Insurance company in writing, certified mail, return receipt requested. The little booklet you get from your employer is NOT the SPD. The reason you need certified mail is simple, that is ERISA working for you. They have 30 days to get you the SPD, if they don't do it, and you have that little green card from the post office, they can get big fines, every single day they go past 30 days. ERISA does offer you some protection, but you must learn what it offers you, or else the insurance company may just walk all over you. Dates are extremely important here.

ERISA is bad for you because the insurance company; They are the ones enforcing the rules of this particular type of coverage, also known as the fox guarding the hen-house. They can terminate benefits at any time of their choosing, and they don't have to worry about being sued for punitive damages, because you cannot do that. YES, that is correct, you can sue them, but you cannot sue them past what they should have paid you in benefits. You can only sue them after you have exhausted the appeals process, sometimes it's one appeal, sometimes it's more, again the SPD is needed here.

This makes it hard to find an attorney who will take your claim, and in most cases, when you get an attorney involved, they will take a percentage of all future benefits involved, but at least your claim will most likely get paid. You will need a special attorney, called an ERISA attorney, if you want to have a real chance at winning in court. If you use any other kind of attorney, they will try to help, but ERISA is so special, they will be learning it on your claim.

To make matters worse here, after you prevail in court, they can cut you off the very next month, and make you do it all over again, they can do this because ERISA lets them get away with it.
This one thing is the biggest problem with ERISA.

Know that this does not happen too often, in most cases, even my own claim, they just pay benefits. I have been cut off before, but I seen it coming, filed an appeal, and was successful, I have never had to sue them in court, I have not used an attorney, not yet at least.

If you are still with me here, and you want to know more, visit the forum below. Be warned, even there, threads are moderated heavily, they are locked, deleted, edited, and it's tough asking questions when you must be so vague about things.
I suggest you just lurk, and read posts for a while, there is a lot of information under the claims section.

If you need an ERISA attorney, that is different, just sign up, post your location, and ask for an attorney, one will get in touch with you, that is no problem, that is something the forum does very well.
They also have an ERISA attorney who frequents the forum, and will post, respond, and help people with their claim, as long as they abide by the endless list of rules....

www.diforums.com

Also, I am not an insurance person, I think insurance is extremely boring. I am a computer guy. I only know a bit about ERISA because I have been on claim for many years. I receive both social security, and Group ERISA benefits each month.

Take Care