Long Term Disability

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It has become a common practice for insurance companies to routinely deny  long-term disability insurance claims as a means of containing costs and increasing profits for the insurance companies that issue the disability policies.

The law governing the disability claims process differs depending on whether your claim is preempted by Federal ERISA law.  ERISA stands for Employee Retirement Income and Security Act.  This distinction generally is determined by whether or not your employers paid part of your disability insurance premium.  It is very common to have a group health disability insurance plan through your employer.  Typically if this occurs, then the insurance plan will be governed under Federal ERISA law and procedures.  If the policy is purchased privately by an individual, the policy is governed by state contract law.

Claims governed under ERISA law are quite different and distinct from normal insurance claims are governed state contract terms.  Most attorneys are not familiar with the legal traps in ERISA-governed claims.  It is important to seek immediate legal help from an attorney familiar with ERISA early in your claim.  Claims governed under state insurance regulators are generally governed by applicable state law and bad-faith insurance company law.  A complete and thorough knowledge of this type of law is necessary to effectively pursue these types of claims.

Process for Filing

The process for filing for benefits can be complicated, and the definition of “disability” can be ambiguous in most policies, the definition of disability shifts from an inability to perform one’s own occupation to an inability to perform “any occupation” after some period of time.  It is very common for insurance companies to cut off claims after the expiration of the initial “any occupation” standard of disability.

The claimants usually have only 180  days to file an administrative appeal of this denial.  In ERISA-governed claims, the administrative appeal is critically important to the claimant in that this is generally the only opportunity for the claimant to submit critical evidence of disability.  If a lawsuit is necessary later on, generally the only evidence considered at trial is the evidence submitted to the insurance adjuster during the administrative appeal.  Therefore, it is imperative to make absolutely certain the adjuster has the medical records and vocational records necessary to prove disability.

This evidence is generally in the form of vocational reports, medical opinion evidence, residual functional capacity reports, objective medical testing, job description evidence under the federal government’s Dictionary of Occupational Titles and affidavits of the claimant and key witnesses.  A key mistake made at this level of the appeal is not submitting key evidence.  The penalty for the claimant is the inability of submitting evidence once a lawsuit is filed.

Insurance companies often deny legitimate claims.  Whether you’ve already been denied benefits or are just now filing and need legal guidance, the Law Offices of John E. Dunlap, P.C. will be glad to help you demonstrate that you are in fact disabled under the terms of the policy and seek a court order for regular payments.  Moreover, we will help in the event your payments have been delayed or you have been undercompensated.  Finally, if you’ve been fired or laid off and intend to file a long-term disability claim, we can help you in that area too.  If you’ve been denied a long-term disability claim, you should not sign anything from the insurance company without first consulting a lawyer familiar with this area of the law.

If you employ our office we will do the following:

Every client’s case is different but this is just a list of things we will do to help you with your long-term disability insurance claim:

Assist in filing insurance forms;

  • Evaluate your insurance claim and advise you on the law and your options;
  • Review your medical records and make suggestions for any additional testing required to prove you case;
  • Supplement your claim file with additional medical records;
  • Obtain your complete file from the insurance company;
  • Obtain medical records and opinion evidence regarding disability;
  • Obtain vocational experts to get opinion evidence;
  • Obtain and develop  functional capacity evaluations;
  • File all administrative appeals;
  • File a medical brief arguing your case; and
  • File a federal court lawsuit if necessary.

Examples of Long Term Disabilities

Whether you have sustained injuries following an accident or have been diagnosed with a chronic illness, if you cannot work and have long-term disability coverage, we can assist you in filing a claim for benefits — or in dealing with the appeals process, if your claim has been denied. 

Some of the conditions that qualify as a disability include:

  • Heart disease
  • Burns and scars
  • Cancer 
  • Fractured bones
  • Lupus
  • Diabetes 
  • Immune system disorders
  • Spinal cord injuries
  • Occupational illnesses 
  • Mental disorders
  • Loss of limbs
  • Traumatic brain injuries
  • Gastric ulcers
  • Dental disorders

Reasons for Denial

Even if you get diagnosed with a severe medical condition or injury, receiving long-term disability benefits is not easy. Various disability insurance policies have different requirements, and your insurer will search for any reason to reject the claims. Knowing the common reasons that a disability insurance company can give for denying long-term disability claims can help increase your chances of success when you file a claim.

Insufficient Medical Evidence

  • Frequent medical treatment – To receive disability insurance benefits, disabled individuals must have adequate evidence to show they’re receiving medical care regularly. You must give proof of every medical examination you’d had that supports your claim, such as x-rays, MRIs, and lab tests if needed.
  • Missing medical records – Sometimes, disability insurance companies deny claims when they don’t get all your health records. Ask your carrier for all the documents the insurer has asked for and those it’s received. Ensure that the insurance company asked for and received all the records supporting your claim. You might need to be persistent.
  • Doctor’s statement – Your doctor’s opinion can play a critical role in proving your disability. You and your LTD lawyer should request your doctor to offer you a written report concerning your work-related health limitations. Don’t rely on the information from your insurer because it is designed to support denial.

Failure to Meet the Criteria That Your Insurance Policy Uses to Define Disability

It is important to check the insurance policy’s description of the specific definition of your condition to determine if you meet it. A disability insurance lawyer can help you make this determination.

Video Surveillance Shows Inconsistencies in Your Disability Claim

If investigators record you doing tasks that are inconsistent with your disability claims, the insurance company might deny your claims.

Failure to Meet Deadlines

Ensure that you take note of any set deadlines when filing and appealing your LTD claim. Basically, you have 180 days to appeal the initial claim, and if you don’t hit the deadline, you might lose your chances to sue your insurer in a federal court.

You have to keep track of lots of moving parts when it comes to long- or short-term disability benefits governed by ERISA. There can also be pitfalls in navigating the different system of Social Security Disability claims. As an experienced disability lawyer, John E. Dunlap can guide you through every part of the application and appeals process. We have a track record of success in helping individuals with disabilities file claims with the best chances of approval and avoid bad-faith denials from their insurance companies. Whether your disability is due to personal injuries or a medical condition, we’ll be in your corner throughout your efforts to secure your well-deserved benefits and an improved quality of life. 

Whether you’re facing an ERISA process or need the expertise of Social Security Disability lawyers, the law offices of John E. Dunlap, P.C. are here to help. Contact us today for a free 20-minute consultation.