Nine Important Things to Know about Long Term Disability Insurance Claims in Florida [Part I]

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

Although long term disability insurance purchased from a private insurance company or provided by an employer as a benefit of employment can offer vital financial security, beneficiaries often face a difficult road when filing a claim for benefits.  The economic model for maximizing insurance industry profits does not revolve around insurers paying the maximum number of claims or the full measure of benefits owed.  Insurance companies deny or underpay a significant number of claims because this strategy generates enormous profits for the insurance industry.  The ability of insurance companies to allow money to remain invested also provides a financial incentive to drag out the claims process.  Below we provide nine important answers to claims-related questions for beneficiaries in this two-part blog.

Can a doctor filing a long term disability insurance claim act as his own treating physician?

Our Florida long term disability claims law firm sometimes receives questions from physicians concerning their ability to serve as their own treating physician.  These doctors inquire about the need to visit a medical professional every 3, 4, or 6 months if the claimant is sure of his or her precise diagnosis and prognosis.  While it might seem like a waste of time to see a treating doctor if you know that he or she cannot help you, the policy requires you to be under the care of a treating physician.  A doctor that does not comply with this requirement will likely torpedo a disability claim.

Can a long term disability insurance carrier deny your claim even if your physician has not authorized you to return to work?

Many people who are still physically unable to return to work are informed by their disability insurance carrier that their claim is being denied.  This is understandably a confusing and frustrating situation because individuals unable to work are told that the financial security they counted on appears out of reach.  Even if the claimant’s physician has not signed off on a return to work, insurers routinely conduct their own medical review.  The insurance carrier might send the medical records to its doctors or to an "independent" doctor for a peer review.  Because these physicians have a financial interest in receiving future business from the insurance company, they tend to be overly optimistic about an employee’s ability to return to work without limitations or restrictions.  The insurance carrier subsequently relies on these favorable reports while disregarding the treating physician’s recommendations.

Can you file a lawsuit rather than an administrative appeal?

The answer to this question depends on the source of your disability insurance policy.  If the policy is provided by your employer as part of your employee benefits package, the claim will probably fall under the auspices of ERISA.  This federal law requires that claimants exhaust administrative remedies before filing a lawsuit.  When a claimant files a lawsuit for disability insurance benefits without an appeal under a policy governed by ERISA, the insured faces a risk that the lawsuit will be dismissed.  However, an individual that purchases a private disability insurance policy can usually file a lawsuit without an administrative appeal.

How should you interpret your insurance carrier’s actions if your insurer pays short term disability insurance benefits under a “reservation of rights”?

If an insurer has not made a final determination regarding the issue of coverage, the insurer might commence temporary disability insurance benefits under a “reservation of rights.”  This legal phrase is intended to avoid having an initial grant of benefits constitute a “waiver” of the carrier’s rights to dispute coverage at a later point in time.  After payment under a reservation of rights, the insurer might terminate benefits or continue normal payment of your claim under the policy.

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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