This is the second installment in our three-part blog post in which we answer important questions about long-term insurance disability policies, the claims process, and challenging a denial. While we have attempted to address many general questions, we invite you to contact us regarding issues directly relevant to your situation.
How does LTD insurance relate to social security or worker’s compensation benefits?
While long-term disability policies are private insurance plans offered by insurers like Harford, Aetna, The Standard and Met Life, social security disability is a government provided program. The programs involve different terms, limits and restrictions. It is important to carefully review your LTD policy because many policies have provisions that permit the insurer to reduce disability payments based on the amount received for an incident or disability through worker’s compensation or social security disability insurance (SSDI).
Does it matter whether state or federal law controls my long-term disability claim?
If you have a choice, you are much better off if your claim is controlled by state law because ERISA, which governs LTD claims under federal law is notoriously pro-insurer. Further, state courts can be more hospitable because a jury, which might be sympathetic to a policyholder mistreated by policyholders, often decides the case. In federal court, a claim governed by ERISA will be decided by a federal judge. The legal standards applied in federal court also make appealing a denial more difficult. Federal appellate judges considering the appeal of a decision in favor of the insurer might be legally required to apply the “abuse of discretion” standard, which is a much more difficult standard of review when appealing a trial judge’s ruling.
What do I do after my disability claim has been denied?
If your insurance company denies your claim, you will receive a letter that references an “appeal” process. Generally, you will be required to exhaust any administrative appeals before filing a lawsuit. The denial letter you receive will include critical information, including the deadline to request an administrative appeal. The appeal will be handled by a different division of the insurance company, so policyholders need to make sure they send their request for an appeal to the right address.
Policyholders might want to consider retaining an attorney during the administrative appeals process though legal representation is not mandatory. While an administrative proceeding is less formal than a courtroom hearing, there are still compelling reasons not to wait until you are embroiled in litigation in court to hire a disability claims lawyer. The information that might be considered later by a judge if you file a lawsuit may be limited to evidence presented during the appeal.
What kinds of evidence may be used to appeal a denial of benefits?
There are many types of medical reports, doctor opinions, and diagnostic scans that might be effective when challenging a disability benefits denial. Examples of relevant evidence might include but are not limited to the following:
- MRIs, CTs, or other diagnostic scans
- Independent medical evaluations (IMEs)
- Insured’s sworn statement describing functional limitations
- Functional capacity evaluations (FCEs)
- Video footage showing your functional limitations
- Evidence from treating doctors
- Opinions from medical specialists in practice specialties relevant to your disability
What deadlines apply to filing an administrative appeal of your disability claim denial?
If you have disability insurance purchased directly from an insurer, the policy and letter denying your appeal will indicate the deadline for filing an appeal. When a policyholder is pursuing a claim under a policy governed by ERISA, the deadline will typically range from 90 to 180 days during which you must submit evidence in support of your appeal.
If you have questions about your disability insurance or your insurer has denied your claim, we might be able to help. We invite you to continue reading Part III of this blog post or speak to us if you have specific questions about your circumstances. My law firm represents policyholders in claims disputes in Miami and throughout Florida. The Law Firm of J.P. Gonzalez-Sirgo, P.A. offers free consultations and case evaluations. No Recovery, No Lawyer Fees. Call 305-461-1095or Toll Free 1-866-71-CLAIM.