By: Elliott Andalman, Attorney at Law
Most LTD claims are made by employees covered under group policies issued by employers. The rules governing the administration of these claims are regulated by federal law, specifically ERISA (the Employee Retirement Income Security Act), which covers virtually all employee benefits. Many employees make the mistake of assuming that their LTD coverage will work like medical insurance coverage and that they will be paid LTD benefits because they’re too sick to work. Unfortunately, it’s not that simple. Every claim submitted to LTD insurance is scrutinized by doctors and medical personnel they hire. This results in many unpleasant surprises for sick employees. By the way, everything noted in this article can also apply to those employees who have STD (Short Term Disability) coverage as well as LTD.
The Plan document is your key to success. Under ERISA, each employer is allowed to contract with insurance companies for the coverage provided to employees, who are beneficiaries of the contract, or Plan. The exact terms and conditions of your coverage are determined by the contract or Plan document. Most employers provide this coverage by contracting with an insurance company. That contract, also known as the Plan Document, is the key to finding out what you need to know to bring your claim successfully. Unfortunately, the Plan document isn’t always easy to read and interpret.
How can you maximize your chances to win LTD benefits? The best way is to consult with an experienced attorney before you apply. It’s important that you and your attorney review the terms and conditions of the Plan, properly complete the application forms, and obtain medical documentation.
Here are eight things you should find out, if possible, BEFORE you file an LTD claim:
1. Get a copy of the Plan. Many employers create a Summary Plan to notify employees about the coverage. Do not settle for a Summary Plan. The Courts have held that your rights are determined only by the Plan, not the Summary Plan, and the Courts have held that you have a right to a copy of the entire Plan document and well as the Summary Plan.
2. Once you have the Plan, read it carefully. It will set forth the definition of disability that you have to meet to get paid benefits. Look carefully because often the definition of disability changes and makes it harder to win after two years of benefits are paid.
3. How much will you be entitled to receive? The Plan will have a clause setting forth the amount of your benefit or how the benefit is calculated under the Plan, normally a percentage of your last salary. It is important for you to know how much your benefit will be if your claim is approved.
4. Familiarize yourself with Pre-Existing Conditions clauses. The Plan will normally have a “Pre-Existing Conditions” clause which may or may not exclude your claim from coverage. Most Plans exclude coverage for any disability that begins within one year after your coverage under the Plan began if the disability is caused by a pre-existing condition;
5. Understand “Other Income”. The Plan will typically have a clause defining “Other Income” which you must be familiar with so you will know what other income may be offset from your LTD benefit.
6. Check for age and benefit limits. The Plan will include a clause advising how long the benefit may be paid, which can vary by claimant age.
7. Get to know what disabilities are excluded. The Plan will have a clause setting forth what types of disabilities are excluded and what type have a special limitation period for payment, which is often two years. Typically, any disability caused or contributed to by mental illness is limited to two years of benefits.
8. You must be in treatment with a doctor who will support your claim. Support will normally consist of filling out an Attending Physician Statement and submitting copies of clinical records. In addition, the insurance company may want to call your doctor to discuss the claim and you may need to ask your doctor for a narrative report. If you’re going out of work because of an illness, it’s important to visit your doctor before you file for disability. The insurance companies are skeptical of claims in which an employee stops work and later gets a doctor to support that he or she went out of work due to an illness.
Navigating the LTD benefits claim maze can be challenging, but we’re here to help. If you need to file a claim and are seeking sound legal counsel, please contact me.
About Andalman & Flynn, P.C.
Andalman & Flynn, P.C. serves clients throughout Maryland and the District of Columbia, offering compassionate, quality service and winning representation across a broad range of legal areas. With a concentration on disability benefits law and family law, the firm focuses on cases that impact the rights of everyone, and they are there for clients when responsive legal help is most critical. For more information about Andalman & Flynn, please visit http://www.andalmanflynn.com, or call 301.563.6685.