What Medical Conditions Qualify for Long Term Disability: Examples + Loopholes

Long-term disability (LTD) can replace your income if you’re unable to work for an extended period due to a qualifying medical condition. However, getting approved for benefits can be difficult and frustrating. 

Policies have specific criteria for determining eligibility, and definitions for qualifying medical conditions can vary from policy to policy. Knowing what medical conditions qualify for long-term disability can be a complex undertaking. 

To avoid surprises or coverage gaps, it is important to understand the conditions of your coverage.

What is long-term disability insurance?

Long-term disability insurance replaces income if your earnings are interrupted by an illness, medical condition, or disability. It can help with financial support when you can’t earn your regular income.

What qualifies as a disability isn’t as straightforward as you might think. You’ll find two common types of LTD policies: Own-occupation and any-occupation. With an own-occupation policy, you’re eligible for disability if you can’t perform the duties of your specific occupation. An any-occupation policy doesn’t qualify you for benefits unless you’re unable to work in any occupation.
For instance, suppose Dr. Patel, an orthopedic surgeon, suffered an unexpected medical condition that caused chronic pain and affected their fine motor skills, and they can no longer perform surgery. In an own-occupation policy, Dr. Patel might be eligible for disability benefits. However, Dr. Patel wouldn't qualify under an any-occupation policy if they could still practice medicine.

Common medical conditions that qualify for long-term disability

Specific medical diagnoses that qualify for LTD vary depending on the insurance policy. However, several common disabling conditions are often recognized, such as bipolar disorder, cardiovascular disease, neurological disorders, and brain injuries. 

A Health and Productivity Benchmarking report released in 2020 by the Integrated Benefits Institute lists the top six reasons for new long-term disability claims:

• Musculoskeletal and connective tissue disorders
• Neoplasms
• Injuries (fractures, sprains and strains) and poisoning
• Circulatory system diseases
• Mental health disorders
• Pregnancy, childbirth and puerperium

Keep in mind that this isn’t an exhaustive list, and which medical conditions qualify for long-term disability depends on your insurance plan.

Which conditions automatically qualify you for benefits?

Certain medical conditions can fast-track your long-term disability claim. It typically involves having a severe impairment that significantly hinders your ability to carry out daily tasks and maintain employment. According to the People with Disabilities Foundation, prime examples are: 

• Total blindness
• Total deafness
• Leg amputation at the hip
• Prolonged confinement to bed due to a persistent ailment

However, these conditions primarily affect Social Security disability applications. Ultimately, it comes down to the language of your disability insurance policy. It’s why reviewing the terms and conditions is crucial to understand the extent of coverage it provides.

Loopholes and potential long-term disability claim denials

Despite the benefits of long-term disability insurance, it isn’t without its faults. Knowing potential loopholes or exclusions in your policy can help ensure a smoother process. Here are a few factors that can affect the success of your claim. 

Pre-existing conditions

In some policies, you’ll find limitations or waiting periods for pre-existing conditions. A pre-existing condition is any medical issue you already had a diagnosis for before requesting coverage. Insurance companies won’t automatically deny your application, but you must disclose your pre-existing condition when applying for long-term disability coverage. 

Insurers can approve you for a policy if you have diabetes, sleep apnea, lupus, and ulcerative colitis. However, you may need to provide medical records or additional documentation that you’re receiving treatment for the condition. 

Mental health conditions

Mental health conditions, while often invisible, can disrupt your ability to perform (and keep) your job. The National Institute of Mental Health estimates that more than one in five adults have a mental illness in the U.S..

Fortunately, mental health conditions are increasingly recognized as valid reasons for disability claims. However, insurance companies might require thorough documentation and can limit your benefit period. Depending on your policy, mental health and nervous disorders might only provide a payout for up to two years, underscoring the need to read your policy carefully.

Alcohol and substance use disorders

Alcohol and substance abuse will impact 10% to 15% of healthcare professionals at some point in their careers, according to National Library of Medicine data. Despite its profound impact on job performance, some insurers limit substance abuse coverage to two years or exclude it altogether.

If you're missing work or facing job loss because of drug or alcohol addictions, review your long-term disability policy for coverage options. It may offer financial support during recovery and treatment.

Hard to diagnose conditions

Ambiguous symptoms or those that require extensive medical testing can make qualifying for long-term disability insurance benefits difficult. Chronic fatigue syndrome and fibromyalgia, for instance, can be hard to diagnose and get benefits for.

Long COVID is another potentially disabling illness that affects as many as 23 million people in the U.S., according to a 2022 Health+ Long COVID Human-Centered Design Report from the U.S. Department of Health and Human Services. However, it’s difficult to prove how debilitating symptoms can be, and denials are common.

If you’re struggling with a long-term disability claim, reach out to your healthcare provider and disability insurance company for help. Confirming the diagnosis and eliminating other potential factors may be possible by looking at patient-reported outcomes, biomarkers, and various tests.

On-the-job injuries

Needle-stick injuries, sprains and strains, back pain, and carpal tunnel are common occupational injuries for healthcare providers. Although many are minor and resolved with the help of workers’ compensation coverage, some can lead to long-term disability claims. 

If you’re disabled on the job, workers’ compensation can cover short-term disabilities and long-term disabilities. While you can be eligible for both workers’ comp and long-term disability benefits at the same time, certain long-term disability policies might not include coverage for on-the-job injuries. 

Does a diagnosis guarantee coverage?

A medical diagnosis for a condition doesn’t guarantee you’ll qualify for LTD benefits. You must also demonstrate that your condition prevents you from performing the essential duties of your occupation for an extended period of time. Here are helpful steps to support the claim and improve your chances of approval:

• Double-check your disability application. Make sure your application is complete, and you’ve answered all questions to the best of your ability.
• Document the condition. Keep accurate records of symptoms, medical appointments, diagnoses, treatments, medications, and complications or side effects.
• Record the impact on job-related tasks. Note difficulties you have in your workplace, accommodations requested or provided, pain levels, limitations, and daily challenges.
• Provide medical evidence. Medical evidence and expert opinions can substantiate your disability claim and provide an unbiased evaluation of the condition and your ability to work. 
• Hire a disability attorney. A long-term disability attorney can help if your claim has been denied or you’re facing challenges in the claims process. But you don’t have to wait until you hit a roadblock — law firms often offer free consultations, and hiring a lawyer earlier can yield better results.

How to apply for long-term disability insurance?

Applying for long-term disability benefits can be a complex process that requires careful attention to detail. It’s easier to navigate the long-term disability claims process when you understand what conditions qualify.

Having the right coverage in place is crucial when considering a long-term disability insurance policy. Fill out the form below for a custom disability insurance quote from SLP Insurance. We can help you secure the disability coverage you need to protect your financial well-being.