10 Things Employees Should Know About Group LTD Claims Governed By ERISA

If you have become disabled and unable to continue to work, you may qualify for long-term disability benefits under an LTD plan with your employer. Long-term disability policies are designed to help you replace some of your income when you become disabled while employed. Most group LTD policies are subject to ERISA (the Employment Retirement Income Security Act), which is a federal law.

Make sure you know everything you can before you file. There are many important things to know about ERISA and long term disability benefits, but here are the top 10:

1. The exact definition of what “disability” means in your policy. Even if your doctors agree that you are unable to work, you must primarily concern yourself with the definition of disability as it is written in your policy. Your disability must satisfy the contractual definition of the term “disability” or you will be denied benefits.
2. Does your policy have a waiting period? Most disability insurance policies have a waiting period of 90 to 180 days. This means that you will have to wait between 90 and 180 days to receive your benefits even if you are approved right away. Make sure you have made payment arrangements with your creditors and talk with your family about your situation so you can be more prepared during this waiting period.

3. Be aware that you may be subject to surveillance when applying for LTD benefits. Insurance companies frequently employ private investigators to scrutinize the activities of claimants. It’s crucial to consistently follow the medical directives given by your healthcare providers, as you never know when you might be under observation. Similarly, it’s becoming increasingly common for insurance companies to monitor the social media activities of those filing for benefits. For example, if your doctor has advised against lifting heavy objects or bending, and an insurance adjuster finds a social media post showing you rock climbing or lifting a grandchild, they might question the veracity of your claim regarding your pain or physical limitations. Exercise caution and be consistent in following medical guidelines to bolster the credibility of your disability claim.

4. Your monthly payment may be taxed. Whether benefits are taxable depends entirely upon who paid the premiums for the LTD benefits while you were working. If the employer paid for the LTD insurance premiums, then any benefits paid under a claim are taxable. If the claimant paid the premiums while working, then the benefits are not taxable. 
5. You will be encouraged to apply for Social Security Disability benefits (SSDI and/or SSI). If you are granted long-term disability benefits, you will probably be encouraged to apply for social security disability. That is because most insurance companies can lower your payments if you receive SSDI/SSI benefits, paying only the difference between your LTD and SSDI/SSI benefits.
6. Your medical record is critical to your claim. Before applying for benefits, talk to your doctor about your intent to apply for LTD benefits. Discuss with your doctor your medical file and make sure your doctor has noted all of your symptoms, including complaints about your pain, which are usually left out by doctors. Make sure all the dates are correct for office visits, and test results are all together in your file.
7. You will likely only receive a portion of your salary. If you are approved, you will not receive your entire salary. You will receive a portion which is usually 60-80%, depending on your policy. Make sure you review the exact terms of your policy to know what you should receive. Plan your new budget with that number minus taxes.
8. Benefits will likely end. Some policies will pay until retirement age, but most policies do have a limit, such as a 24-month maximum or when the claimant reaches age 65. Read your policy to determine how long you can plan to receive benefits.
9. Most mental health claims are limited. Most policies have a minimal amount of time that you can receive benefits for mental health conditions like depression and anxiety.
10. The insurance company decides if you qualify. The insurance company and/or adjuster will determine if you are eligible for benefits. Your case will only go before a judge if you appeal the decision. It’s not uncommon for insurance companies to deny claims the first time.

If you are denied long term disability benefits, you should file an appeal. Under most policies, you can appeal the decision multiple times. It is common for benefits to be denied by insurance companies and move on to a judicial court.

Hiring an experienced LTD attorney to represent you in court is a great way to increase your chances for approval of benefits; The attorney will help you gather facts to support your case and will not get paid a fee until you receive your past-due benefits or a settlement.

Though headquartered in Florida, the Ortiz Law Firm offers its expertise in disability law to clients across the United States. To consult with an experienced Long Term Disability Insurance Attorney, call us at (888) 321-8131 to set up an appointment.