Even though your company may have offered you long-term disability insurance as an employee benefit, the company with which they partnered to deliver this benefit has its own ideas.
Time and time again, an unreasonable insurance company denies employees expecting disability insurance benefits for a crippling injury or illness. While it is a tough fight, you have the legal ability to stand up for yourself and push back. First, you need an attorney who knows how to take the fight to the insurance company, even on their home turf.
At J. Price McNamara ERISA Insurance Claim Attorney, we get results for clients with injuries and disabilities. If you have a long-term disability claim, contact us for assistance.
Table of Contents
- Your Plan Should Pay Part of Your Income While You Cannot Work
- The Insurance Company Makes the Long-Term Disability Claims Process Hard
- What You Need to File with Your Initial Claim
- A Complex Law Called ERISA Governs Your Plan
- Insurance Companies May Try to Take Your Benefits Away
- Call a Baton Rouge Long-Term Disability Lawyer
Your Plan Should Pay Part of Your Income While You Cannot Work
Long-term disability insurance can provide 40 to 70 percent of your income before your illness or injury when you can show that you are disabled. The average duration of a long-term disability claim is 2.5 years, but it can pay you benefits until you qualify for Social Security if you cannot work again.
Each plan has its definition of disability that you must meet to qualify for benefits. In theory, becoming eligible for benefits should not be a complicated process. Your doctor can document your inability to work, and the insurance company should pay you what you deserve since your plan is a contract.
The Insurance Company Makes the Long-Term Disability Claims Process Hard
In practice, it is often not this simple. The insurance company is a self-interested referee, passing judgment on your claim when they are the ones who must pay out benefits. You can understand how this is a recipe for abuse. The same company that must pay you is deciding your entitlement to benefits. The system results in many unjust and unfair decisions, where the insurance company denies benefits to people who are disabled.
From your standpoint, you must put together the most compelling claim possible in the hopes that it will persuade the insurance company to grant benefits. It is certainly possible to have your initial claim approved, especially when you have documentation that shows the extent of your disability. Especially when you have a sizable potential claim (for example, a permanent disability that will keep you from working again), you should work with an attorney to prepare your initial claim.
What You Need to File with Your Initial Claim
You must build a comprehensive claim with the proof necessary to show the insurance company that you meet the plan’s definition of disabled.
You may include the following with your initial claim:
- The test results and scans that show your disability and the extent of it
- A statement from the physician who has treated you and is most familiar with your condition
- Statements from people who know you and observe you every day
- Opinions from vocational experts who know your profession and can testify that you are unable to fulfill the duties of it
Even if you come armed with all this evidence, it may not be enough to persuade the insurance company to grant benefits. The insurance company knows that if they grant benefits, they will need to pay hundreds of thousands of dollars, or even more, over the life of your claim. Even though practically everyone else in this world may see the reality of your situation, the insurance company can have millions of reasons to ignore that reality.
A Complex Law Called ERISA Governs Your Plan
When your employer provides long-term disability insurance as an employee benefit, different rules apply. Employee benefits fall under a statute called ERISA.
While lawmakers passed the law to protect employee benefits, it put procedures into place that favor insurance companies. However, ERISA does not give insurance companies a blank check to disregard the promises they made to you in the plan documents. You can still hold them accountable in court no matter how much they fight (and they will).
Insurance companies have a wide latitude to deny claims if they can find a colorable reason to do so. They will not give you the benefit of the doubt in any respect. You cannot sue insurance companies under state law claims for bad faith. While they occasionally face government scrutiny and fines, it does not stop them from making your life difficult in any way they can.
Why Insurance Companies Deny Long-Term Disability Claims
Insurance companies may deny your claim, giving one of the following reasons:
- They do not think that you meet the plan’s definition of disabled.
- They hired someone to conduct surveillance on you, and they believe they have evidence that can undermine your claim
- They claim that your condition was a pre-existing one that the terms of your plan do not cover
- There is insufficient evidence to persuade them of the extent of your disability
- Their doctors disagree with the conclusions that the treating doctor who examined you initially reached
- They claim that you did not follow the requirements of the plan in applying for benefits
A claim denial is not the end of the road for you when you seek benefits. It can begin a long and challenging process to fight the insurance company a process you must go through to receive long-term disability benefits.
The insurance company must provide you with a reason why they denied your claim. They must also provide you with the documents they relied on to reach their decision. If you are not already working with an attorney, now is the time to call one. You can add documents to your file and respond to the insurance company in a way that can address their concerns.
You Have to Appeal to the Insurance Company
Unfortunately, the first place that you need to go to contest your claim denial is the insurance company itself. As futile as this may seem, it is something that ERISA requires. The insurance company will get the first chance to review your appeal.
No matter how much the insurance company promises objectivity in reviewing your case, you cannot expect the fox to guard the henhouse. The chances are that they will deny your appeal because they do not make money by granting benefits.
However, ERISA requires you to put as much effort into the insurance company appeal. You only get one chance to build the record for the appeal. Both the federal district court and the insurance company will use the same record to decide whether you can get long-term disability benefits.
The federal judge will not allow you to add anything to the record. No one will call you to testify. There are only limited exceptions that will enable you to build the record. If you did not put full effort into building the record, you won’t get a second chance to fix any mistakes.
The Insurance Company Does Not Get the Last Word
If you lose your insurance company appeal, a federal judge will provide you with a review of your case. At this point, you will get an objective decision maker for the first time in your case who has no financial self-interest.
The federal judge may use one of two standards of review, depending on the language in your plan:
- A de novo review where the judge decides your benefits based on their independent review of the record and not considering what the insurance company had to say
- A review of the insurance company’s decision to determine whether it was unreasonable
Either way, the federal part of the legal process can help you overcome a biased and wrong decision denying you benefits. Before you get to that point, you must work to strengthen the record after the insurance company first lets you know that they denied your claim. You can add information that they claimed was missing to have a better record, knowing that you may end up in federal court eventually. The insurance company may even try to settle your case because it does not want to lose and make a new legal precedent.
How You Can Win an ERISA Long-Term Insurance Appeal
Federal courts can overrule the insurance company based on some of the following grounds:
- The insurance company wrongfully ignored the opinion of your treating physician in favor of their “independent” doctors whose only relationship to the claim is that the insurance company paid them to review your file
- You did present enough documentation for the insurance company to conclude that you were disabled
- The insurance company misread the plan's definition of disability, making it more strict than it was on paper.
- The insurance company took snippets of information out of context when they claimed that surveillance found that you were not disabled.
You Can Fight and Win
Many decisions explaining the appellant's victories in these cases reveal situations in which any rational human being can have found that you were unable to work. However, the incentives are powerful for insurance companies to put their whole hand on the scale to deny you benefits.
Although ERISA does not make it easy for you to fight the insurance company, you can win when you find an experienced ERISA long-term disability insurance attorney to champion your case.
If you do not win at the federal district court level, you can take the case further. You can proceed to the federal appeals court to review the district court judge's ruling. The appeals court can only review the district court judge's decision, and they cannot take new evidence.
Long-term disability benefits are critical for your family's financial support when you can no longer work. These claims will pay you benefits until you can work again. For some claimants, these benefits will last until when they would have retired. You can also accept your payments in a lump sum when you settle with the insurance company.
Insurance Companies May Try to Take Your Benefits Away
Even when the insurance company grants benefits, they may try to take them away at some point. Insurance companies will argue that you can do some work, notwithstanding your condition. Many plans pay for a set period when you cannot do the job that you did.
After that period, the plan’s definition of disability may change to being unable to do any work at all. At this point, the insurance company often tries to tighten the screws and remove people from their roles. You can also fight this decision through an appeal.
Never try to take on an insurance company without the help of an experienced lawyer. These companies know exactly what they are doing because they have done the same thing for as long as they have sold long-term disability insurance.
You must have an advocate who knows how to beat insurance companies at their own game when they have to answer in a forum that is not skewed towards their advantage. Even though the process may favor the insurance company, the law must be objective and respect their rights.
Call a Baton Rouge Long-Term Disability Lawyer
Never try to take on the insurance company alone. They have an army of adjusters and litigators whose interests differ from yours. Insurance companies make money by denying every claim they think they can deny. Being denied benefits when you need them most can be devastating.
J. Price McNamara ERISA Insurance Claim Attorney fights for clients who have wrongfully had their long-term disability insurance claims denied by a conflicted insurance company. We can also work with you before you file the claim in the first place to help you build the most potent possible file. Your benefits are too important to leave anything to chance.
To schedule your initial consultation, reach us online or call us at (225) 201-8311. You do not owe us anything unless you win your case.
Baton Rouge Office
10455 Jefferson Hwy,
Suite 2B
Baton Rouge, LA 70809
Phone: 225-425-7917
Fax: (225) 201-8313
(By Appointment)
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