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Depending on the situation, contractual language, and the reason for the limitation, you may be able to extend private disability insurance benefits if they are set to expire or have been discontinued. But the process requires extensive effort.

Disabilities can hit professionals suddenly as the result of an accident or slowly due to the development of a chronic condition, but in either situation, there is no way of telling how long the disabling condition will continue to prevent you from working. Yet disability insurance policies often include built-in expiration dates that limit benefits to a specific period.

If your disability continues to prevent you from practicing your profession and your benefits are due to expire, it is a good idea to review your policy and determine the best options for extending coverage. Working with an experienced disability insurance attorney who understands how to read between the lines of insurance policies and knows the key issues that create exceptions to standard limitations can be very helpful.

Why Are Benefits Expected to Be Discontinued?

One of the first issues to address is why benefits could be discontinued. The policy may state a maximum time limit, and that limit may be approaching. Or the claimant might have been approved for benefits as long as a certain condition remains in place, and that condition is changing.

Another situation that could cause disability benefits to be discontinued is when coverage transitions from “own occupation” coverage to “any occupation” coverage, or when the definition of a qualifying disability changes in some other way. Eligibility then narrows considerably, and claimants often fail to meet the qualifications.

Finally, some situations involve an insurance company announcing its intent to terminate benefits and providing little or no explanation. The method for addressing these issues will differ in each situation, but analyzing policy language will always be a crucial part of the process. Therefore, it is wise to obtain a copy of the full policy terms and review them in detail.

Certain policies, such as short-term disability insurance policies, are designed to provide coverage for a very limited period. You may not be able to extend benefits for this type of policy. However, a claimant may be able to establish eligibility for benefits based on a separate disabling condition.

What Does the Policy Say About the Maximum Benefit Period?

To get the direct, actionable language about a specified maximum duration of benefits, it may be necessary to review:

• The certificate of coverage
• The full insurance policy
• Benefit determination letters
• Policy amendments and riders
• The summary plan description

The language that establishes a maximum benefit period is not always easy to spot. It might specify that benefits will terminate on a particular date, but the limitation could also be phrased differently. The policy might specify a maximum benefit period. Or the policy might include an age-based limitation explaining that a claimant is no longer eligible for benefits when they reach “retirement age” or milestone age such as 65.

The limitation on the duration of benefits might be linked to a particular level of recovery or change in condition. It is possible that the limitation might be described in one way on a summary plan description and a different way in the language of the full policy or a policy rider or amendment. In these situations, it helps to work with an attorney who can argue for the interpretation most favorable to your interests.

Can Disability Benefits Actually Be Extended?

You have no specific legal right to extend the duration of benefits under your disability insurance policy, but your situation may provide grounds to reconsider a decision to terminate benefits. Some reasons for continued benefits that we’ve encountered over the years include:

• Provisions in the policy that allow for continued benefits when particular conditions are met
• Benefits were terminated prematurely according to the terms of the contract
• The claimant’s condition does not fall within the limitation relied on by the insurance company
• The wrong limitation period was applied
• An additional condition provides grounds for benefits under a separate claim

A knowledgeable attorney can identify grounds to request a continuation of benefits.

What if Your Condition Has Not Improved?

While it may seem logical that benefits should continue if your disability remains unchanged, lack of improvement does not automatically provide legal grounds to override a contractual limit on the duration of benefits. If, however, the insurer terminates benefits because it insists you no longer meet eligibility standards, you can use your condition to justify continued benefits.

Medical evidence will be the key in this situation. You will need documentation to show that:

• Your physical, mental, or cognitive impairment still exists
• You are receiving ongoing treatment as required by the terms of your policy
• Your impairment prevents you from performing specific tasks necessary for your occupation or similar occupations.
• Your treating physician has established restrictions and limitations that have been updated to account for your current condition

The documentation might include diagnostic tests, statements from physicians and vocational experts, treatment records, and results of functional limitation assessments.

What is a Condition-Specific Limitation on Benefits?

Some disability insurance policies limit benefits for certain conditions. As an example, many disability policies limit benefit payments for substance abuse disorders to 24 months.

If your benefits are about to be terminated because of a condition-specific limitation, review the provision carefully and compare it to the reality of your situation. For instance, the policy may define the condition in a way that it doesn’t apply to your case. Or the limitation might apply only to certain symptoms or conditions that are not the source of your disability. Your insurer might cite the cap on benefits for substance abuse disorders when the true source of your disability is an anxiety disorder that is not subject to the 24-month limitation.

Remember, the insurance company may try to apply any limitation it can conceivably use, hoping you’ll accept it. You are not obligated to agree with their assessment, and you can appeal their decision.

What if The Definition of Disability Changed During the Benefit Period?

One way insurance companies try to limit the amounts they pay under disability insurance policies is by including contractual language that changes eligibility standards after a policyholder has been receiving benefits for a while. The policyholder’s condition might fail to improve or even worsen, but when new standards are applied, that policyholder suddenly is no longer considered “disabled” under the new definition.

This frequently happens with the vocational part of a disability definition. The policy might initially pay benefits if a professional cannot perform the duties of their own occupation. A chiropractor with debilitating back pain, for instance, might receive benefits because the condition makes it impossible to provide hands-on care to patients. However, the policy might specify that after two years, the chiropractor will be considered disabled and eligible for benefits only if the condition prevents the practice of any occupation, not just the occupation practiced at the time the disability began.  

Then the insurance company might insist that the chiropractor could do other jobs and therefore terminate benefits. In this situation, the insurance company’s assessment might be correct, or it might be completely unrealistic. Carefully analyze the policy terms to determine which occupations qualify. 

You should also consider the tasks required for the alternative occupations the insurance company proposes to see whether limitations prevent the policyholder from performing job duties. Policyholders need documentation of the extent of their disabling condition and detailed information about how the condition limits their ability to perform critical job-related tasks.

FAQs About Extending the Duration of Disability Benefits

How do you seek continued disability benefits?

Generally, if you want to request or pursue continued disability benefits, it is a good idea to:

• Review the terms of the policy carefully
• Identify the provisions that establish the limitation on the duration of your benefits
• Determine how disability is defined specifically in your coverage
• Secure and organize medical evidence to demonstrate your disabling condition and resulting vocational impairments
• Review the insurance company’s explanation of why benefits will be discontinued
• Identify any errors (legal or factual)
• Determine the deadline for appealing determinations of the insurer

An attorney can help at every stage of the process and may be able to find additional ways to get benefits continued or reinstated.

What if the insurance company denies an extension?

If you have solid legal grounds to overturn the decision, your attorney may help you pursue relief through a lawsuit. If the insurer acts in bad faith, it may face additional liability.

Can the insurance company terminate benefits before the maximum benefit period?

The policy terms may allow an insurer to terminate benefits before the maximum benefit period expires if certain conditions are met. For instance, the insurer may determine that the policyholder’s condition has improved to the point where they no longer meet eligibility requirements. 

Or they may decide the policyholder violated the policy, such as by failing to receive appropriate care. An experienced disability insurance attorney can review the situation and determine whether the insurer acted within its legal rights under the policy or whether the policyholder deserves reinstatement.

If Your Disability Benefits Are Being Discontinued, Find Out Whether You May Be Eligible for Relief

When a disability insurance policy clearly sets a time limit that has been reached, it can be difficult to justify extending benefits. However, in many situations, insurers make errors in determining coverage limitations, and policyholders deserve to have those errors corrected.

At Seltzer & Associates, we have dedicated our practice to helping professionals obtain and keep the benefits they are entitled to under their policies. To find out whether we can help you obtain continued benefits in your situation, schedule a free consultation with our team by contacting us online or calling 888-699-4222.