Long-Term Disability Questions and Answers

Your health insurance pays for your medical bills, but what about your other monthly expenses if you are unable to work due to a disability? Disability insurance is meant to replace your wages and help with expenses if you cannot work due to a disability.

If you have a group policy, you should contact human resources to file a disability claim. If you have an individual disability policy, you should contact your broker or insurance agent.

ERISA allows insurance companies to extend their time to make a decision. All the insurance company has to say is that they need more information. Delaying payment of claims is a tactic to force your return to work.

A physician’s letter that states you are disabled and unable to work will not guarantee that your claim will be approved. However, depending on the letter’s substance, it may improve your chances.

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 legal action against the insurance provider.

Using an experienced long-term disability attorney can help you build a strong case, but it is not required.

You can file an appeal by obtaining evidence to support your claim and submitting that evidence to your insurer with an appeal letter. We offer a free step-by-step guide to appealing a disability insurance claim denial.

Under ERISA rules and regulations, you only have 180 days from the insurance company’s denial letter date to file your appeal. If you have a private disability insurance policy, your appeal deadline will be specified in your denial letter.

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 its rules and guidelines, and the insurer must decide based on the terms of the disability insurance policy. 

Most long-term disability insurance policies have a provision that allows the insurance company to terminate certain claims for long-term disability after two years.

The primary difference between group and individual policies is whether ERISA governs the policy. 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 claims for bad faith damages.

The Employee Retirement Income Security Act (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.

With an “own occupation” policy, you may be disabled from your specific occupation but able to perform other work, yet be unable to find it. If so, you may qualify for disability benefits and unemployment benefits.

Other income may reduce Supplemental Security Income (SSI) benefits, but it does not reduce Social Security Disability Insurance (SSDI) benefits.

HIPAA laws grant you a right to privacy. Therefore, no medical provider should give access to an insurance company without your express consent.

If you see multiple doctors for your disability, they should each provide a statement supporting your claim. It is a “best practice” to have at least two doctors provide you with letters you can submit to the insurance company.

Your residual functional capacity (RFC) is the most you can still do despite your impairment(s) and any related symptoms.

When you fail to follow the treatment plan recommended by an attending physician, you are considered a “non-compliant” patient. Your non-compliance will be noted in the medical records, which could lead to your claim’s denial.

Consult your policy for the exact percentage of your salary that your long-term disability insurance will pay. 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.

If your doctor says you cannot work, but your claim is still denied, ask your doctor to complete a residual functional capacity form. This will help outline the tasks that the doctor believes you are not able to do safely without injuring yourself further.

Examples of bad faith by an insurance company after a policyholder files a disability claim include failing to conduct a thorough investigation, unfairly delaying claim processing, and wrongfully denying a claim. If your long-term disability claim falls under ERISA, you cannot sue for bad faith or punitive damages. You can only sue for the benefits owed because ERISA pre-empts state law claims like bad faith and punitive damages.

If you have a group policy, you must follow the insurance policy’s terms and go through each step of the mandatory appeal 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.

If federal ERISA regulations govern your claim, your state’s insurance laws are “pre-empted,” meaning your state’s Department of Insurance has no jurisdiction.

The “arbitrary and capricious” standard of review is a legal principle used by courts to assess the decision-making process that applies to most ERISA long-term disability claims.

The best time to hire a long-term disability attorney is during the appeal stage. An experienced LTD attorney must review the claim file at the appeal stage to determine what additional medical or vocational proof needs to be added to the administrative file and what adverse information needs to be rebutted.

There are many reasons to hire the Ortiz Law Firm to help with your LTD claim. We are dedicated to compassionate client service and outstanding results. Mr. Ortiz has represented long-term disability claimants nationwide since 2005.