Nine Important Things to Know about Disability Insurance Claims in Florida [Part II]

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

This is the conclusion of our two-part blog post providing important answers to common questions asked by beneficiaries.  While we have answered some of the most common general questions we receive, the best way to get specific questions about your situation is to talk to an experienced Miami disability insurance claims lawyer. Click this link to read Part I.

How does receipt of worker’s compensation benefits impact my disability claim?

Worker’s compensation benefits generally will be considered an offset against disability benefits if the policy is a group plan provided by your employer.  ERISA applies to such policies, and your disability benefits might be reduced in proportion to your worker’s compensation payments.  The question is less clear if you have a privately purchased individual disability plan.  This issue typically will be governed by the language of individual policies, so this is another example of the importance of obtaining legal advice and carefully reviewing your insurance policy.

Am I permitted to earn any income while receiving disability benefits?

A policyholder’s right to earn income depends largely on the type of disability policy.  If your policy uses an occupational definition of disability, you might be able to earn income pursuing a job outside your prior career.  If your policy includes a broader definition of disability, then earnings you receive from work in any job might be offset against your disability payments.  An insured receiving $4,000 a month in disability payments who accepts a job making $2,000 per month in a different occupation could see his or her disability payments reduced to $2,000 per month.  Before purchasing long-term disability coverage, policyholders need to carefully review the policy.  If you are not sure whether the policy permits you to engage in an alternate career while receiving benefits, you should seek legal advice regarding terminology or provisions that are not clear.

What if a disability carrier is stonewalling a policy?

Disability carriers frequently engage in an intentional strategy of delaying payment as long as possible.  The insurance company profits from this delay because the money that would be paid out on a claim can continue to earn a return on investment.  If the insurer is still processing your claim after ninety days, you should contact an experienced Florida Disability Claims Lawyer who will recognize these tactics and understand the most effective strategies to force insurers to stop dragging out the claims process.

How should an insured proceed when an insurance carrier ignores the policyholder’s ERISA appeal?

If you do not hear back from the insurer on your appeal within 45 days, you might want to immediately consult with a Miami Disability Attorney about filing a lawsuit.  Filing a lawsuit under these circumstances permits the claim to be framed in terms most favorable to the policyholder.  The judge can determine whether you are disabled rather than the case being decided based on whether the carrier exercised reasonable discretion in denying the claim.  If you have not retained counsel to this point, legal representation will generally be necessary to successfully navigate the procedural, substantive, and evidentiary rules applicable to a civil lawsuit.

Can my disability carrier deny my coverage if I decline to undergo a surgical procedure recommended by my treating physician or the insurer’s medical expert?

Generally, an insurance company does not have the right to compel a claimant to submit to an operation or undergo surgery.  If your orthopedic surgeon or neurosurgeon recommends an operation on your back, for example, disability benefits cannot be conditioned on the decision to undergo the invasive intrusion of surgery.  There can be exceptional situations where an insurer cites a case in which the policyholder refuses a medical procedure characterized by the carrier as “surgery”.  Disputes based on the insurer’s attempt to deny your claim based on such reasoning can turn on complex medical evidence, so you should seek the expertise of an experienced disability attorney.

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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