More Frequently Asked Questions by Long Term Disability Insurance Claimants

J.P. Gonzalez-Sirgo
Founder of J.P. Gonzalez-Sirgo, P.A.

What can you do if your claim is delayed or denied?

The appropriate steps depend on the type of long-term disability insurance coverage.  If the policy was provided by an employer as a benefit of employment, the policy is probably part of a group plan which typically is covered by ERISA.  This federal law imposes very specific procedures and policies applicable to appeals.  An administrative appeal must be pursued to appeal a denial under ERISA, so you will want an experienced disability insurance claims attorney to protect your interest.  While you can eventually pursue relief in a lawsuit, you must first exhaust your administrative remedies.

If you are appealing a denial or termination of benefits, you will need an ERISA claims attorney because the procedures are complicated.  Further, the evidence that may be used if your appeal proceeds to litigation will usually be limited to the record established prior to filing of the lawsuit.

Policyholders who have purchased a long-term disability insurance policy outside the employment relationship are not subject to ERISA law.  The requirement that you exhaust administrative appeals before filing a lawsuit does not apply to private long-term disability insurance policies.

What timing requirements apply to filing a long-term disability insurance claim?

While the individual policy will determine when “proof of loss” must be provided to the insurer, the usual deadline is sixty or ninety days.  If you miss the deadline, you should never backdate the notice of claim.  We may be able to help claimants that face problems like failing to file a timely proof of loss.

Do you need to attend an Independent Medical Exam?

Generally, long-term disability insurance policies require policyholders to submit to an independent medical examination (IME).  In reality, these medical evaluations do not remotely resemble anything close to “independent.”  These physicians are chosen and paid by the insurance company.  These medical professionals are fully aware that their chances of being hired for subsequent claims depends on a pro-insurer report.  This type of report is the exact opposite of an “independent report.”  Sometimes it is advisable for clients to bring a family member to the appointment who can observe and take notes or videotape the evaluation process.

Can you handle your own disability insurance claim if you have successfully handled an auto insurance claim on a prior occasion?

Long-term disability insurance claims are subject to a far more complex process than auto insurance claims.  The complex legal framework under ERISA makes it extremely risky to attempt to pursue an ERISA disability claim without legal representation. 

You can reach Miami Insurance Claims Lawyer J.P. Gonzalez-Sirgo by dialing his direct number at (786) 272-5841, calling the main office at (305) 461-1095, or Toll Free at 1 (866) 71-CLAIM or email Attorney Gonzalez-Sirgo directly at [email protected].

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