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Long-term disability insurance can provide you with income when an injury, illness, or other medical condition prevents you from working. It can cover from 50-80% of your pre-disability salary, and you can obtain coverage in a variety of ways: • From group long-term disability insurance (e.g., as part of your employee benefits package or through a professional affiliation)
• From an individual long-term disability insurance policy
• From a combination of group and individual long-term disability insurance Understanding the scope of your long-term disability policy Long-term disability policies are contracts and they can be hard to interpret. A long-term disability insurance attorney can help you master the fine print. Some critical terms that can affect the outcome of a long-term disability denial case:
• An “own occupation” policy: To obtain benefits you have to show that you’re unable to perform the material and substantial duties of your own job.
• An “any occupation” policy: To obtain benefits you have to show you are unable to perform, with reasonable continuity, the material duties of any job. It may be harder to show that you are unable to perform any job and unfortunately, many group insurance policies are “any occupation” policies. Long-term disability denial letters Even valid claims can be denied, requiring you to wade through confusing insurance policy language at a time when you’re most vulnerable. Under the Employee Retirement Income Security Act (ERISA), a long-term disability denial letter must:
• Identify reasons for denial based on your policy
• Identify any criteria or guidelines used to make the denial
• Identify any material or information you need to provide to obtain your benefits
• Tell you how you can appeal the denial
• Inform you of deadlines for filing an appeal If your denial letter doesn’t include this information, send a copy of the letter to your insurance company, along with a complaint within 180 days. You should ask for a copy of your long-term disability policy for your records. You also have a right to any reports that the insurance company relied upon in denying your claim (e.g., such as any reviews by an insurance company doctor). You need to be able to address each point that the insurance company makes with evidence and arguments of your own. Appealing a long-term disability denial You should show your denial letter to your physician right away so that you can address any issues raised by your insurance provider. A typical subject of disagreement is whether your injury, illness, or condition, truly prevents you from working. Physicians may not always be aware of the best way to document your case. A long-term disability insurance attorney can work with you and your physician to identify the types of records that are most likely to address an insurance company’s concerns. For example, you should gather: • Doctors’ notes
• Medical records
• X-rays
• Laboratory results
• Records of administered medications Statements by employers and coworkers, videotapes and photographs, and statements by experts also may bolster your case. Can I skip an appeal and go straight to court? If your policy is governed by ERISA, you may have to go through an appeals process first. This is an administrative proceeding and while that may make it seem less serious than a court case, there’s a lot you can lose. For example, if you don’t put all your favorable evidence and arguments on the record, you may lose your right to present this information at a later court trial. That’s why it’s important to get the advice of a long-term disability attorney even at the appeal stage. If you live in Alabama, Florida, Georgia or Tennessee and have questions about long-term disability benefits denial, please visit the website of Burke, Harvey & Frankowski, LLC today.
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