When people talk about Texas long-term disability insurance benefits, they are usually referring to money received to assist with expenses when they become unable to work due to an illness or injury not related to their jobs. Long-term disability assistance is also available through the Texas workers’ compensation program for those injured or made sick due to conditions at work, but the benefits and handling of claims is entirely different even though benefits are usually paid by an insurance company.
Long-term disability insurance benefits available in Texas may vary according to a number of factors. Unfortunately, the most common factor in the equation is a reluctance on the part of insurers to pay benefits without a fight. So, those seeking benefits often choose to work with an experienced insurance attorney to assist with the process.
Disability insurance provides income to make up for wages lost when someone is unable to work because of an illness or injury. The amount provided is generally between 50 and 80 percent of average wages, but this amount may decrease due to offsets from other sources of income. Some employees receive or purchase disability insurance in a group plan through their employer, while others purchase coverage on their own.
Coverage is typically offered for short-term and long-term disabilities under two different types of policies. While short-term disability insurance usually pays benefits more quickly, long-term disability insurance generally pays benefits for a longer period of time—potentially up to retirement age.
Although Texas long-term disability insurance benefits often cover situations different than those covered under workers’ compensation insurance, long-term disability insurance may pay benefits when an employee is injured on the job and is not covered by workers’ compensation. It may alternatively pay benefits in addition to those received from workers’ compensation insurance.
Texas state law does not require employers to provide long-term disability insurance benefits for their employees. However, when employers do offer plans, both state law and federal law impose certain requirements and restrictions to protect the rights of employees who rely on these benefits.
Texas Administrative Code §3.1203 prohibits insurers from including “discretionary clauses” in policies issued from 2011 onward. These types of clauses give insurers great discretion in deciding whether to pay a claim, so the ban holds insurers to a more objective standard.
At the federal level, the Employee Retirement Income Security Act (ERISA) requires long-term disability plans provided by employers to follow certain rules. For example, these plans must provide specific information to all beneficiaries, including the standards used to determine what constitutes a “disability” under the policy.
One important factor to keep in mind with regard to long-term disability insurance benefits in Texas is that the provisions of the policy itself determine the situations in which benefits can be paid, as well as the amount of income received and the length of time benefits are provided. An insurance policy is a contract, so provisions of the policy may be interpreted in accordance with contract law.
In an attempt to keep costs low, many insurers that provide long-term disability benefits routinely deny claims. Fortunately, various state and federal laws provide a process for appealing denials of Texas long-term disability insurance benefits. In many instances, though, claimants must exhaust administrative remedies before filing a claim in court.
Because the contractual terms of long-term disability insurance policies are often complex and difficult to understand, many people in Texas elect to consult a knowledgeable attorney to learn whether they should be covered under a plan. A seasoned Texas insurance lawyer could also assist with appealing denials to help claimants receive reasonable benefits for their disabilities. Call today to schedule a consultation and discuss your situation.
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