Long-term disability insurance is offered to help support you as a wage replacement in the event that you’re sick or injured and unable to work. Unfortunately, what should be a relatively straightforward insurance claim process is anything but simple. Despite paying your premiums for months, years, or even decades, your insurance company may unfairly deny your disability insurance claim, leaving you without the steady income replacement you were expecting.
What is Long Term Disability Insurance?
Long Term Disability benefits (sometimes referred to as “LTD” benefits for short) provide vital income protection to individuals beginning a few weeks to a few months after the onset of a disabling condition. It typically kicks in once the Short Term Disability benefit period ends.
As with Short Term Disability insurance benefits, LTD benefits are designed to replace a specific percentage of your pre-disability income starting a few weeks or months after the onset of a disabling illness or accident. Policies typically provide coverage until retirement age, which is usually defined as age 65 in the policy, but may also be specifically defined in the policy.
You can typically purchase Long Term Disability Insurance benefits from an insurance agent or through your employer.
Some benefits you might obtain include:
- Bi-weekly or monthly benefit payments, which will pay you a portion of your pre-disability earnings on a bi-weekly or monthly basis for the term length of your policy; and
- Comprehensive Rehabilitation Program benefits, which can provide benefit incentives related to vocational (job) rehabilitation, dependent (child) care, workplace modifications and more.
What Does My Policy Cover?
Long Term Disability is designed to cover a wide variety of illnesses and ailments. Some people think that long-term disability only covers injuries that happen on the job. However, although on-the-job injuries may be covered, more than 95% of long-term disability claims are believed to be non-work-related. For example, injuries suffered outside of work, cancer, auto-immune disorders, mental illness, chronic illnesses, neurological disorders, and degenerative diseases are likely to be covered by a long-term disability policy. This list is by no means a complete list but gives you examples of conditions that may qualify for benefits.
Here, we look at a general overview of the claims process and appeals procedures in ERISA disability claims.
The ERISA Claims Process
- The first thing you should do is contact your employer’s human resources department for your disability insurance plan’s specific procedure details. Do not simply make this request verbally. Make the request in writing. Your disability insurance company should send you a written procedure or application for free.
- Make sure you note any deadlines to file the claim.
- File the claim before the deadline.
- The insurance company may request additional information in order to make a determination on the claim. The insurer will advise you of any deadlines to submit the additional information. Remember it is your burden to prove you have a disability. It is not the insurance company’s burden to prove you are not disabled. Therefore, provide whatever documentation necessary to satisfy your “burden of proof.”
- If you are approved, then you will start drawing your benefits. If you are denied, your insurance company should advise you of its decision in writing. If you received a denial, you have the right to appeal the decision.
- Make sure to note any deadlines to file your appeal. The deadline is likely in the insurance company’s denial letter.
- File your formal notice of appeal within the time limits, typically 180 days.
- The insurance company will again review your appeal, and will issue a new decision. If your claim is approved, you will begin to draw your benefits and any past-due benefits. If you are denied, then the insurance company should advise you of your appeal rights in the denial letter.
- Once you have exhausted all of your administrative appeals, you have the right to file a lawsuit in federal court, challenging the insurance company’s wrongful denial of your claim.
Sick or Injured, but Have Not Yet Filed a Claim
Complex claim paperwork is the last thing on your mind when you are struggling with sickness, illness or an injury. While you may have a long term disability policy, you may not know what benefits the insurance contract affords, what the policy covers, how to file a claim, the time limits to file a claim, and what you need to do next. This is where The Ortiz Law Firm can help. Our free book on Long Term Disability can help you recover the benefits you may be entitled to. Topics in the book include:
- Understanding Your Policy;
- Common Mistakes in Filing a Claim; and
- When to Seek Legal Advice From an Attorney.
Applied For Benefits and Waiting on a Decision for Coverage
If you’ve applied for long term disability benefits and you still haven’t heard a response from your long term disability insurance carrier, you should contact them for the status of your claim. Intentionally delaying a claim decision is one way that some insurers demonstrate bad faith in their failure to honor their contract with you. Without an official denial, you’re unable to appeal. However, you may have the right to go right to court under certain circumstances
Applied For Benefits and Denied Coverage, but Appeals Are Still Available
Too often, legitimate long term disability claims are denied or wrongfully terminated because insurance companies look for every possible legal and technical reason to deny or cut-off a valid claim. In most circumstances, you have the right to file one or more appeals with the insurance company in the event that your initial application is denied. If you have been denied coverage for benefits, you should make sure you appeal the decision using the administrative process outlined by your insurance company. If you were previously receiving LTD benefits and the insurance company wrongfully terminated your benefits, you also have the right to appeal the cessation of benefits.
However, you should also keep in mind that appeals are not always required before filing a lawsuit in certain circumstances. That’s why you should consult with an experienced LTD attorney to discuss your legal rights.
Applied For Benefits and Denied Coverage, and All Administrative Appeals Have Been Exhausted
At some point, there will be no more appeals available to you directly with the insurance company. In such an event, the insurance company will tell you that you have “exhausted” all of your administrative appeals. You then have the right to sue the insurance company in State or Federal Court.
Representation by an Attorney in a Long Term Disability Claim
The Ortiz Law Firm handles Long Term Disability (LTD) claims at every level, from the initial application to all levels of appeal. We handle LTD claims at:
- the initial claim level;
- the first administrative appeal;
- the second administrative appeal;
- all “optional” levels of appeal;
- litigation claims in state court (for individual disability insurance claims, church plans, and government employees); and
- litigation claims in federal court for ERISA claims.
Mr. Ortiz is an experienced long term disability attorney. He and his staff assist claimants in filing internal “administrative” appeals with the insurance company in an effort to maximize the chances that your LTD claim will be approved or reinstated.
If you want assistance with your claim or if your denied appeal has been rejected, know your rights and options. If your LTD claim has been denied or cut-off, then contact us for an absolutely free, no-obligation long term disability denial case evaluation. Mr. Ortiz handles most appeals on a contingency fee basis, which means that there is a fee on the final recovery of past-due benefits. If there is no recovery, then there is no fee. If you are thinking of applying for benefits, Mr. Ortiz offers hourly consultations at a competitive rate. Call us at (866) 853-4512 today.