Definition of Totally DisabledWhat is the definition of totally disabled? Each long-term disability plan offered to employees under ERISA will not be the same. Each policy is a contract, and employees should expect the terms of it to be honored. One concept that is the same across insurance policies is that an employee must be totally disabled to qualify for long-term disability benefits.
Although the definition of the term may vary from policy to policy, the general concepts are the same. The employee must have an illness or condition that keeps them from working. However, the definition of a total disability will change over time. For more information, reach out to a long-term disability lawyer.
The Insurance Company Will Always Interpret the Policy Language Against You
No matter what definition of the term your plan uses, the one constant is that the insurance company is doing everything in its power to avoid paying you what you may deserve under the terms of your policy. They have a framework and an infrastructure that they will deploy against you at every turn. Regardless of their sleek advertising campaigns telling your employer that these plans give you peace of mind, the only real interest is the insurance company’s own finances.
While the definitions of total disability shouldn’t vary much, the insurance company wields great power. Because they write the policy, they can determine the definition of total disability on their own.
Insurance companies are known for using small tricks on the margin to try to make it tougher for you to qualify for benefits. They define the term as narrowly as possible to make certain claims impossible. The insurance company may even read requirements into your plan that never existed in the first place.
ERISA Has Insurance Company-Friendly Procedures
The problem is that ERISA is not an employee-friendly law in its procedure. Nonetheless, the law gives you the legal right to fight back if the insurance company has wrongfully denied your claim or has terminated your benefits.
First, contact an experienced ERISA attorney. That is the best way to hold an insurance company accountable because they only get to set all the rules if you let them.
The Definition of Totally Disabled Is Different at First
At first, your plan will have a more lenient standard for what qualifies as a total disability.
Initially, when you are attempting to qualify for benefits, the insurance company will review your medical file to determine whether you can perform the duties or your own occupation that you had before becoming injured or sick.
For example, if you suffered a serious back injury, you cannot perform physical labor to complete your work under the terms of your insurance policy. It does not matter whether you can perform other types of work - the main yardstick is whether you can do this particular job.
The Insurance Company Can Still Make a Lower Standard Difficult
One common trick is that the insurance company substitutes the word occupation for job in the definition of total disability.
Notice the difference here. You may physically never again perform the duties of your own job, but the insurance company might argue that you can still perform the duties of your occupation—a similar position with different requirements.
In doing so, they might argue that your occupation is broader than your actual job. Even if the argument seems to strain logic, the insurance company can get away with using it against you. Claimants cannot sue an insurance company for bad faith for denying ERISA claims, so they have the incentive to be aggressive in denying claims.
Do not mistake a more lenient standard with the insurance company easily granting you long-term disability benefits. They have two general ways that they deal with long-term insurance disability claims - they are either extremely difficult or borderline impossible.
The insurance company will still try to find a way to deny the claim. They will make some arguments about why you can work, perhaps arguing that you can adjust how you work despite your injuries. They may dispute that you are as injured as you say.
The Definition of Totally Disabled Tightens After an Initial Period
The challenge for a disabled worker is that the definition of total disability will change after the worker receives benefits for a certain period. Usually, this is roughly 18 to 24 months, depending on the language of the individual plan.
You can expect that the insurance company will perform a review of your benefits around that time. They try to cull claims where they think they can avoid further benefit payments. Here, they will be looking for reasons to terminate your benefits however they can.
At that point, “total disability” shifts from not performing the duties of the job you did before the injury to not performing any gainful work at all. The insurance company expects you to look for any work that you can possibly do, given the limitations of your disability.
The standard after 24 months becomes much stricter than the already strict metrics that the insurance company applied to your initial claim. The insurance company expects you to return to work in some capacity if you can. If you suffered an injury that leaves you unable to do physical labor, the insurance company might expect you to work somewhere in a clerical capacity. Then, you will be doing less physical work that may be possible with your disability.
The Insurance Company Will Often Say That You Can Work
The insurance company often makes rosy and unwarranted assumptions when they are considering what you may be capable of, given your condition. It is not always easy or feasible for you to completely shift gears and begin a new vocation, especially after you have suffered a serious injury.
You cannot magically turn on a dime and switch careers, but that is exactly what the insurance company seems to expect. Long-term disability insurance companies have a self-interested and conflict-laden viewpoint of what you can do because it saves them money.
An Independent Medical Examination Can Signal Imminent Trouble
The insurance company will usually request that you attend an examination with an “independent” physician when it wants to verify your status and determine whether you can work.
If you ever receive this letter, get an ERISA long-term disability insurance attorney immediately. These so-called independent doctors have a financial incentive to say what the insurance company wants. They get repeat business from the insurance company, which can certainly give business to other professionals if the doctor keeps reaching conclusions that cost the insurance company money.
In some cases, you may not even get a notice that the LTD insurance company is reviewing your benefits. Courts have held that the insurance company can terminate benefits based on a comprehensive review of your medical records. They may or may not try to speak with you first.
In one case, an insurance company cut the benefits of a woman who was receiving payments for three-and-a-half years after a five-minute doctor’s appointment and a so-called “independent review” of their medical file.
You Can Appeal a Denial or a Termination of Benefits
Many long-term disability insurance appeals happen after the insurance company has cut off benefits after this two-year period. The insurance company might determine (in their own view) that you can do some work, and they may cut off your benefits entirely.
For them, the decision can save the company over $1 million since you may have otherwise been receiving benefits for the rest of your working career. In the case mentioned, a court noted that the employer (with a self-funded plan) saved itself $2.5 million by terminating the employee’s benefits.
You can appeal the decision to terminate your benefits the same as you will a denial, and the legal procedures are similar. When an insurance company terminates your benefits, you have limited time to appeal.
Under ERISA, you file your first appeal directly with the insurance company. Although it seems like a waste of time to go directly to the company that just cut off your benefits, it is what the law requires. You cannot get an objective review of your case until the insurance company has denied your appeal.
Not only must you participate in the insurance company appeals process, but you must treat it seriously. You are only allowed to introduce evidence and build a record at this phase of the case.
You May Need to Go to Federal Court to Get an Objective Decision-maker
Assuming that you lose at the insurance company appeals phase (it is a good bet to make this assumption, although anything is possible), you will need to bring your case to federal court, where the judge will review the insurance company’s decision.
Depending on the policy’s language, the judge may give some or little weight to the insurance company’s decision. Nonetheless, you have multiple levels of review available to you in federal court. If the district court does not rule in your favor, you can take your case to an appeals court, where the judges will review the district court decision to see if they made an error.
You can always get an objective review of your case at some point since the insurance company process is anything but objective. There are many cases where federal judges skewer insurance companies for underhanded tactics and unreasonable claim denials. However, you cannot take action against the insurance company itself because the law does not allow for bad faith lawsuits after ERISA claim denials.
Many cases regarding a cutoff of benefits are extremely contentious and can drag on for years. The insurance company knows it can wear you down because you may become increasingly desperate for money. In some cases, they may use that as leverage for a settlement agreement, even knowing you have a strong case against them.
You Can Expect the Following Challenges in ERISA Claims
Although ERISA claims may involve many uncertainties, there is little doubt about:
ERISA gives the insurance company built-in advantages, regardless of what Congress intended when it passed the law in the first place.
It is virtually impossible to take on a powerful insurance company on your own, given the procedures that ERISA mandates.
You have tight timeframes in which you can act to appeal the insurance company’s actions.
Although the insurance company has some power, they are not all-powerful, and a court can rule in your favor if you prove that you meet the plan’s definition of disabled.
You stand the best chance of succeeding in your fight against the insurance company when you hire an experienced attorney to handle your case.
When you decide to take on the insurance company, you must be ready to be in it for the long haul because your case can take a considerable amount of time.
You Need a Disability Benefits Attorney to Level the Playing Field in the ERISA Claims Process
If you are appealing a claim denial or benefit termination, you will not need to pay an ERISA attorney anything unless you win your claim. There is little chance of winning your case without the right professionals, especially because it relies on complicated legal arguments and medical information.
The insurance company has constructed an entire apparatus to keep you from getting the money you may deserve under the terms of your policy. You need your own tools to fight for the benefits you deserve.
Whatever roadblock the insurance company tries to put in your way, an ERISA attorney can help you try to find a way around it. A federal court should have a persuasive case file to review that illustrates your individual situation and shows you deserve benefits under the law and the language of your long-term disability policy. Your long-term disability attorney can ensure you present solid evidence to your insurance company, which is then what the court will review.
Always discuss your options for a disability benefits appeal with a skilled long-term disability insurance lawyer.
J. Price McNamara
Losing my own brother, then my father and sister after long, disabling illnesses just a few months apart drove a career change for me. Before that experience, I never truly understood the place you’re in. I never understood the dramatic impact that receiving (or not receiving) the disability and life insurance benefits you paid for and counted on can have on your life especially when you need to focus on family and healing. What I experienced with my own family now drives the way I view my clients and my work, and I will never forget it!