By Elliott Andalman, Esq.
Long Term Disability (LTD) insurance coverage provided by employers is a very valuable benefit of employment. It can be a lifesaver for employees who become too sick to work. LTD provides monthly income, often in the amount of 60% or 66.6% of your last salary.
However, workers cannot take this coverage for granted. The federal law that controls most of these policies is ERISA, the Employee Retirement Income Security Act. Unfortunately, this act often allows the insurance company the discretion to interpret the terms and conditions of the policy and determine whether the evidence is satisfactory to establish disability. This discretion can result in unexpected denials of claims and wreak havoc with the lives of disabled workers.
Tips to Avoid Denial of Your ERISA Claim
In order to try to avoid denial decisions there are a few common sense rules that workers should follow:
- Before you file a claim, get a copy of the insurance policy or “plan” document. Do not settle for a “summary plan”. The Courts have ruled that the terms of the plan are controlling, not the summary plan.
- Read the plan. It contains important information about how to file a claim, what is the definition of disability, and what claims are limited or excluded from coverage.
- Know the rules on pre-existing conditions. Virtually all plans will not pay for a disability that begins in the first year of coverage under the plan if it was the result of a pre-existing condition. You must know how the plan defines a pre-existing condition and when the exclusion ends. If you file for disability benefits too soon for a pre-existing condition, you are just giving the insurance company an excuse to deny your claim.
- Know the definition of disability. The definition varies from plan to plan. Often the definition of disability for the first two years of disability is that you are “unable to perform your own occupation”, and after two years of benefits the definition of disability becomes more difficult and is that you are “unable to perform any occupation that you are qualified for by education, training or work experience”.
- Know if there are limitations on benefits for certain types of illnesses. Most plans limit benefits for “mental disease” to two years. Sometimes plans will make exceptions for certain mental illnesses such as schizophrenia, bi-polar disorder or dementia.
- Visit your doctor. Do not go out on disability unless you have a treating doctor that has advised you to stop working or agrees with your decision to stop working. The insurance companies will normally deny these claims unless you have a treating doctor who reports that you are no longer capable of working as defined in the plan.
- File your claim in a timely fashion. These policies have time limits on when a claim should be filed. If you file after that time limit your claim may be denied. You are giving the insurance company an excuse to deny your claim.
- Be aware that most LTD policies have an elimination period. It runs from the first date of disability until the policy owes benefits. That is often 90 or 180 days, though it can be longer or shorter. Be aware of when benefits should start so you can make plans for how to cope with the elimination period, though some workers will have short term disability benefits or other sick leave benefits that can cover the elimination period.
- Make sure to stay in treatment, even if it is difficult to pay the doctor bill. If you do not stay under a doctor’s care, you are just giving the insurance company another excuse to deny your claim.
- Think twice before writing a post on social media that gives the impression that you can work. Insurance companies routinely check the internet when they evaluate worker claims. Anything you write on social media may be used against you by the insurance company. Don’t give the insurance company an excuse to deny your claim.
Let the Experienced LTD Lawyers at Andalman & Flynn Help You
One way to try to minimize making mistakes on your application for disability benefits is to work with an experienced attorney. While we cannot guarantee that our clients will win, Andalman & Flynn attorneys maximize the chances that our clients will win because of our legal and medical knowledge developed in helping hundreds of workers obtain disability benefits over the last 20 years. If you need helping filing your ERISA claim or navigating other aspects of LTD insurance, contact Elliot Andalman at 301-563-6685 or [email protected] today!
You may also be interested in…
- When Does Pre-Existing Condition Clause Prevent LTD Coverage?
- Disability Retirement Applications Must Be Timely Filed
- Processing Disability Benefit Claims: What Has Changed?