Are you seeking information and tips to help you maximize your chances of winning your disability case?
The information on this site is written by Nick A. Ortiz, a Board Certified Disability Attorney in Pensacola, Florida. He handles group Long Term Disability (LTD) claims, individual disability insurance policy claims, and ERISA disability claims for claimants across the United States.
Here he answers some of the most frequently asked questions about short term and long term disability insurance claims, denials, and appeals.
Q: What is disability insurance? Do I really need it?
You have a 1 in 4 chance of becoming disabled before retirement age. Disability insurance is meant to replace your wages and help with expenses in the event that you cannot work due to a disability.
Short term disability insurance policies typically provide benefits for a limited time, usually between three to six months, although some policies may last up to a year. The benefits usually begin after a waiting period, which can be as short as a week or as long as a month, depending on the policy.
Usually, long term disability policies pay approximately 60% of your earnings. There is also usually built in elimination or waiting period where the benefits are not payable until a certain period after you stop working, usually after you’ve been unable to work for 90 or 180 days.
Q: How do I file a long term disability claim?
If you have a group policy you should contact human resources to file a disability claim application. If you have an individual disability policy you should contact your broker or insurance agent.
Q: Is there a time limit to appeal a long term disability denial?
Under ERISA rules and regulations, you only have 180 days from the date on the insurance company’s denial letter to file your appeal. If you have a private disability insurance policy, the deadline for you to appeal will be specified in your denial letter.
Q: The insurance company has denied my appeal. What can I do?
If you have exhausted all of the appeals available to you under the terms of your policy, you may have no choice but to file a lawsuit against your insurance carrier. Depending on the carrier, you may be able to negotiate a settlement before bringing a legal action against the insurance provider.
Q: If Social Security has approved my claim for disability benefits, how can the insurance company deny my claim?
The insurance company is not bound by the decision of any other agency, including the Social Security Administration. This is because the SSA makes a decision based on their rules and guidelines, and the insurer must make a decision based on the terms of the disability insurance policy.
Q: Can a doctors letter get me approved for LTD benefits?
A physician letter that states you are disabled and unable to work will not guarantee that your claim will be approved. However, depending on the substance of the letter, it may improve your chances.
Q: How long can I expect to receive LTD benefits?
Most long-term disability insurance policies have a provision that allows the insurance company to terminate certain claims for long-term disability after twenty-four months.
If the insurance coverage is under a group policy provided by the insured’s employer, the policy is likely governed by ERISA, which protects the insurance company from bad faith damages.
Q: What is ERISA and what does it have to do with my claim?
ERISA is a set of federal regulations that apply to insurance policies obtained through your employer, union, or employee organization that supersedes, state laws that govern employee benefits plans.
Q: Can I receive LTD benefits and unemployment benefits at the same time?
With an “own occupation” policy you may be disabled from your specific occupation, but able to perform other work, and yet unable to find other work. If so, you may qualify for disability benefits and unemployment benefits.
Q: Do disability insurance benefits offset the benefits I receive from Social Security?
SSI benefits may be reduced by other income like disability insurance benefits. However, if you have Social Security Disability, then there is no reduction of your Social Security benefits.
Q: Do I need a lawyer for my long term disability claim?
Most attorneys do not have the knowledge or experience to properly handle an ERISA-governed LTD claim. Unrepresented claimants may miss deadlines or fail to address critical issues in the appeal.
Q: Do I have to be permanently disabled to get long term disability benefits?
It is common for people to receive benefits until the policy expiration date or retirement, but you don’t have to be permanently out of work. Some people even improve enough to return to work.
Q: What is a medically determinable impairment?
A medically determinable impairment that results from anatomical, physiological, or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques.
Q: Does the insurance company have access to my records if I do not give them consent?
HIPAA laws grant you a right to privacy. Therefore, no medical provider should give access to an insurance company without your express consent.
Q: Is it okay to send more than one doctors letter to the insurance carrier?
If you see multiple doctors for your disability, they should each provide a doctor’s letter. It is a “best practice” to have at least two doctors provide you with a letter for the insurance company.
Q: What is residual functional capacity, or RFC?
Your Residual Functional Capacity is the most you can still do despite your impairment(s), and any related symptoms, such as pain, which may cause physical and mental limitations.
Q: Can my claim be denied for failure to follow doctors orders?
When you fail to follow the treatment plan recommended by an attending physician, then you are considered to be a “non-compliant” patient. Your non-compliance will be noted in the medical records.
Q: How much does long term disability pay?
Consult your policy for the exact percentage of your salary that you will receive. Usually, the number is between 50% and 80% of your gross salary. Some policies will only pay you a set amount per month regardless of your salary, so it’s always best to review your policy.
Q: Why is the insurance company delaying payment on my claim?
ERISA allows insurance companies to extend the time they have to make a decision. All the insurance company has to say is that they need more information. It’s a tactic to force your return to work.
Q: What should I do if my doctor says I cannot work, but the insurance company denied my claim?
Ask your doctor to complete a residual functional capacity report. This will help outline the tasks that the doctor believes you are not able to do safely without injuring yourself further.
Q: When is an insurance company considered to have committed a “bad faith” denial of a claim?
In ERISA disability litigation, the terminology used is a little different than “bad faith.” Federal courts will review the insurance company’s decision to determine whether the denial was “arbitrary and capricious.”
Q: How do I appeal a long term disability denial on my own?
Read the denial letter and request your free copy of your claim file from the insurer, obtain evidence to support your claim, and submit that evidence to your insurer with an appeal letter.
Q: Can I sue my insurance company for denying my disability insurance claim?
If you have a group policy, you must follow the terms of the insurance policy and go through each step of the appeals process before you can sue your insurance company. If you have an individual policy you may not be required to file an appeal before filing a lawsuit.
Q: Should I file a complaint with my states department of insurance?
If your claim is governed by federal ERISA regulations, then your state’s insurance laws are “pre-empted,” which means your state’s Department of Insurance has no jurisdiction.
Q: What is the arbitrary and capricious standard?
The “arbitrary and capricious” standard is a standard of review that applies to most ERISA long term disability claims.
Q: When should I hire a lawyer?
The best time to hire a long term disability attorney is the appeal stage. It is essential that an experienced LTD attorney review the claim file at the appeal stage in order to determine what additional medical and/or vocational proof needs to be added to the administrative file and to determine what adverse information needs to be rebutted.
Q: Why hire the Ortiz Law Firm?
There are many reasons to hire the Ortiz Law Firm to help with your claim. We are dedicated to compassionate client service and outstanding results. Mr. Ortiz has over a decade of experience in representing disability claimants in seeking benefits, and we are not a “mill” firm that will represent just anyone that calls. The Ortiz Law Firm accepts approximately one in ten applicants that request legal assistance.
If you would like to discuss these or any other disability insurance questions with an experienced attorney, please call us at (888) 321-8131. We would welcome the opportunity to discuss your claim. The consultation is free, and there are no fees unless we win your claim.
Our Long Term Disability Glossary may also help you understand key terms in disability insurance plans and policies.