Long Term Disability Denial
You may have been paying long term disability insurance premiums on your own, or you may have been covered by a plan offered through your employer as a benefit. Either way, you expect that you and your family will be protected financially if you become too sick or injured to work. Most people believe that if they can no longer work, and their doctors confirm they can no longer work, LTD insurance benefits should be paid. Unfortunately, these very reasonable expectations are often unmet, as insurers routinely deny claims even where a treating physician confirms that the patient is disabled.
An Extended Disability Can Be Incredibly Costly
The risk of an extended disability during our working lives is higher than the risk of early death. Moreover, the cost to a household of having the primary earner become disabled can far exceed the financial cost of his or her early death. In either scenario the household has lost the income of the primary earner, but in the event of disability, the household still must take care of the surviving, but sick or injured, family member.
According to statistics published by the insurance industry (and used to sell disability policies), almost one-third of Americans entering the workforce today will become disabled before they retire. Over 51 million Americans – 18% of the population – classify themselves as fully or partially disabled. A typical, non-smoking 35 year old female, who leads a healthy lifestyle still faces a 24% chance of becoming disabled for 3 months or longer during her working career; with a 38% chance that the disability would last 5 years or longer, and with the average disability for someone like her lasting 82 months.
In short, prolonged disability is a substantial risk for working Americans. It is safe to assume that the vast majority of U.S. workers are in no financial position to withstand a prolonged disability without some form of disability insurance. A career ending disability without insurance is a recipe for a quick trip to the poor house.
Many of us have recognized this risk and have either secured LTD coverage through an employer or have had the foresight to purchase private LTD insurance. However, the insurance companies sometimes don’t deliver what they promised.
Disability Denials Are Common with Many Insurers
An illness or injury that keeps you from working is always a blow, both financially and emotionally. Disability insurance policies typically pay only a fraction of what the employee or professional was making before an illness. But when an insurance company denies a claim altogether, the financial consequences can be devastating. If this has happened to you, you are not alone. Faced with the prospect of paying a stream of benefits over years, insurers sometimes search for a basis upon which to deny claims. There are specific proof requirements, mandatory procedural hurdles, and deadlines for filing these disability claims. It is easy to get tripped up by the process or by a misunderstanding of the scope of coverage.
Long term disability policies are either group policies provided by an employer as a part of a total compensation package, or they are policies purchased by an individual privately. Employer sponsored disability policies are governed by federal law, the Employee Retirement Security Act or ERISA. Individually purchased plans fall under state law. Federal and state law claims are different in many ways, including applicable deadlines, procedures, legal remedies and available damages. An experienced long term disability attorney should be able to readily ascertain the governing law and understand all the implications.
ERISA is a federal law that Congress enacted to provide “enhanced protection” of the rights of employees to their benefits. In the forty years since ERISA was enacted, it has become increasingly clear that ERISA has backfired in that purpose. Claimants covered by individually purchased policies may fare better: disputes are tried in state courts, and a jury is allowed to add monetary penalties if it finds the insurer acted in bad faith — up to 50% of the value of the claim.
On the other hand, if your ERISA claim has been denied, your only recourse is an Administrative Appeal with the insurance company, subject to review by a federal judge, with no jury trial, no calling of witnesses, and no ability to present any evidence of your disability other than what is contained in the insurance company’s file. ERISA also “preempts,” or eliminates, any claims for bad faith damages.
Reasons for Denial
With an individual policy, your insurance company is obligated to act in good faith in investigating and deciding your claim. Since insurance companies have more to lose if found guilty of bad faith at trial, they are less likely to deny your claim without a valid reason under state bad faith laws than under ERISA, where bad faith damages are disallowed.
Insurance Company Tactics for Avoiding Payment of Claims
Sometimes insurers interpret vague language in their policies to justify the denial of a claim. Here are some of the reasons often stated for claim denials:
- You haven’t provided sufficient medical evidence.
- Your medical evidence is not “time concurrent” for the period of time in dispute.
- You may not be able to perform your job as performed for your employer, but you are able to perform “your occupation as ordinarily performed in the national economy. “
- You haven’t met the definition of disability under the policy.
- Your impairment is related to substance abuse, a preexisting condition, or subjective symptoms.
- Video surveillance indicates you are performing activities not consistent with your claim.
- You didn’t meet a filing deadline.
Having an experienced long term disability attorney working with you can prevent or reverse a denial and get you the benefits you need and deserve.
Why You Need Legal Representation for Group and Individual Long Term Disability Claims
Regardless of which of the two types of policy you have, if you are unable to perform your job and require long term disability benefits, you need a long term disability lawyer in your corner. You will need a lawyer who understands the nuances of your policy and who can determine if the insurer has applied it properly. You will need a lawyer with a strong understanding of medical issues, and who is willing and able to develop the proof necessary to explain how your medical condition prevents you from working. You will need a lawyer who is willing to speak to the witnesses who know you best, and who can corroborate how your poor health has changed your life, at work and elsewhere. Beyond that, the lawyer’s functions will be somewhat different depending on which type of policy you have:
- With an individual policy, your case will be decided in a jury trial under your state’s contract and insurance laws. Your lawyer’s courtroom acumen and trial preparation ability will be important factors in winning a decision in your favor.
- If you have an employer-provided policy, usually governed by ERISA, your lawyer will need to have a detailed understanding of federal law, the importance of the ERISA administrative appeal process, and how to pursue the claim in federal litigation if necessary.
Getting Specialized Legal Help for Your Georgia Disability Claim
If you are about to apply for disability benefits in Georgia, or if you have applied and been turned down, you will find the specialized legal representation you need at the Atlanta law firm of Evans, Scholz, Williams, & Warncke, LLC. Very few attorneys handle long term disability cases as a primary practice area; few lawyers have the specific, focused, and detailed knowledge and experience of private disability law, or the record of personalized service and successful outcomes that you’ll realize at our firm. These cases are complex, labor-intensive, and demanding, and the outcome of your case will have a profound effect on the remainder of your life. Call today for a free telephone interview to learn how we can help.