Even outside of work, workers have many opportunities to become sick or injured. A serious motor vehicle accident or sports injury can leave you disabled. You can even slip and seriously injure yourself from falling. Regardless of the type of accident, your ability to work will be in serious jeopardy. That is why injured workers need long-term disability insurance.
When workers suffer from long-term illnesses, they can rely on long-term disability insurance to provide financial compensation. Many workers will have difficulty keeping up with their finances if it were not for long-term disability insurance. That is why when workers receive a denial of their disability claim from the insurance company; it can feel devastating.
If the insurance company has wrongfully denied your long-term disability benefits, J. Price McNamara ERISA Insurance Claim Attorney can help. We have stood up for our clients for over 25 years, and we can evaluate your legal options.
Table of Contents
- Long-term disability insurance
- How workers can benefit from having long-term disability insurance
- Medical Conditions that Long-term Disability Insurance Covers
- Long-term Disability Insurance Features
- How a long-term disability lawyer can help
- Speak to a Houston long-term disability lawyer today
Long-term disability insurance
Long-term disability insurance is part of an employee's benefits package. This type of insurance can offer workers financial benefits when they cannot work due to their injury or illness. Depending on the terms and conditions of the policy, long-term disability insurance can benefit workers until retirement age.
How workers can benefit from having long-term disability insurance
While workers take time off to recuperate from long-term illnesses or injuries, they can receive between 50 percent and 70 percent of their wages through long-term disability insurance. This is especially beneficial for workers in physically demanding or dangerous occupations.
Suppose you have to come to terms with the fact that your ability to work has been permanently affected. In that case, your long-term disability benefits can still cover your household expenses for an extended time. Even better, long-term disability insurance can offer financial coverage for medical conditions that other benefits do not cover.
Medical Conditions that Long-term Disability Insurance Covers
Every long-term disability insurance policy defines a disability differently. However, policies will generally accept most medical conditions that seriously affect a person's ability to work as medical conditions that long-term disability insurance can cover.
Some examples of medical conditions that can qualify for long-term disability benefits include:
- Asthma
- Bipolar disorder
- Hearing loss
- Chronic fatigue syndrome
- Carpal tunnel syndrome
- Knee injuries
- Post-traumatic stress disorder
- Sleep disorders
- Loss of speech
- Eye disorders
Long-term Disability Insurance Features
While each insurance policy varies, each long-term disability insurance policy contains:
- Monthly benefits. The average long-term disability policy allows workers to receive at least 60 percent of their gross income in benefits.
- Elimination period. The elimination period is how long the worker must wait until they can receive their benefits. It starts from the day that the worker first becomes sick or injured and continues for whatever period the worker chooses. Most long-term disability insurance plans have an elimination period from 90 days to two years.
- Disability definition. The long-term disability policy also contains what the insurance company will consider a “disability.”
- Coverage options. The policyholder is allowed to determine how long coverage will last. Some plans offer one-year, two-year, five-year, and even lifelong coverage.
- Reporting. All long-term disability policies contain special instructions on how policyholders can file claims.
Various definitions of disability in long-term disability policies
Regarding the policy's disability definition, some long-term disability policies contain their own-occupation and any-occupation policies. Own-occupation policies are policies that grant coverage to workers who are unable to perform the job duties associated with their specific occupation.
Any-occupation policies, on the other hand, are a policy that only benefits workers when the insurance company has determined that they cannot work in any occupation. The key difference between the two policies is how the definition of “total disability” is applied. For example, own-occupation policies consider a “total disability” as a disability that prevents the worker from performing all duties related to the policyholder’s occupation.
Filing a long-term disability claim
While each long-term disability policy varies, long-term disability claims usually begin when a claimant fills out an application online, over the phone, or in person. When filling out an application, claimants must provide credible medical documents explaining the claimant’s injury and the limitations associated with the injury. After the insurance company receives the claim, they may request the claimant undergo an independent medical examination.
What is an independent medical examination?
An independent medical examination is a medical assessment that insurance companies can subject a claimant to regarding a long-term disability policy. During a medical examination, the physician does not perform any medical treatment on the claimant. Instead, the physician asks the claimant questions about their disability and medical history.
Many claimants do not want an independent medical examination performed for justifiable reasons; however, the insurance company has the right to deny your long-term disability claim if you refuse an independent medical examination. Therefore, it is better to attend the independent medical examination and dispute any questionable results later than to refuse to participate altogether.
How to act during the independent medical examination
While attending an independent medical examination, the doctor and their staff will monitor you from the second you step into the office. Answer the physician's question as honestly as possible without volunteering additional information they did not ask for. This includes information outside of your medical history, such as the dynamics of your workplace. If possible, take as many notes as possible of the medical examination. Take particular note of the questions that the physician asks you
What Happens When They Deny Your Long-term Disability Claim?
Receiving a denial of your long-term disability claim can be traumatic. You risk your family's financial security. When you receive a denial letter from the insurance company, it can seem like the end of the world. However, it's not. You still have several legal rights that you can practice to obtain your long-term disability benefits.
Why should you consider filing for an appeal?
Despite what the situation may appear to be, you have nothing to lose when you pursue your long-term disability rights. Suppose you have followed the correct procedures and truly qualify to receive benefits. In that case, there is no justifiable reason why you should receive a denial of benefits—nor should you accept it. The appeal process you will have to follow depends on the type of long-term disability insurance you purchased.
If your long-term disability insurance is through a private insurance group, you can follow the state laws in pursuing your disability benefits. If you purchased your long-term disability insurance through your employer, you must follow the federal ERISA laws.
What is ERISA?
ERISA, also known as the Employee Retirement Income Security Act, is a federal law that allows certain federal protections to employees and their benefit plans. Through ERISA, employees have the right to hold a plan administrator accountable for any abuse or wrongdoing regarding their benefits packages. Suppose any inappropriate actions with a benefit plan result in a significant loss for the employee. In that case, the employee can hold the plan administrator liable for restoring that loss.
How does ERISA affect your long-term disability policy?
When you purchase your long-term disability policy through your employer, ERISA automatically covers your insurance policy. That means you must follow the ERISA appeal process when filing an appeal for your claim. Just like retirement and life insurance policies, disability insurance policies are the benefit packages covered through ERISA.
ERISA guidelines when filing an appeal
During an ERISA appeal, claimants must respond to the insurance company's decision with an administrative appeal. The claimant has 180 days to submit an administrative appeal and an administrative record with all the new evidence.
The claimant must submit the following documents to the insurance company within the designated time frame or risk losing the chance of pursuing an appeal permanently. If the claimant still receives a denial with their administrative appeal, the claimant can file a federal lawsuit against the insurance company.
Filing a federal lawsuit
Before being allowed to file a federal lawsuit against the insurance company, the claimant must undergo the administrative appeal process. After exhausting that option, can the claimant hold the insurance company liable in federal court? The federal lawsuit will not proceed like a traditional lawsuit.
Instead of presenting your case to a jury trial and introducing new evidence to the court, a federal judge will evaluate your case. The judge will look at all of the evidence presented in your administrative record and decide based on that evidence.
How a long-term disability lawyer can help
Going up against a conglomerate like an insurance company can seem intimidating. Even when you know that the insurance company committed a violation against you, figuring out how to prove that in a court of law can overwhelm you.
At J. Price McNamara ERISA Insurance Claim Attorney, our Houston long-term disability lawyers have experience with designing successful strategies against insurance companies. We are knowledgeable when it comes to the ERISA laws and the appeals process. Our long-term disability lawyers can assist your case in several ways.
Prepare Your Appeal for Success
Our long-term disability lawyers have the experience to successfully navigate your appeal. Missing deadlines is one common reason why claimants fail to overturn their denials. We know the tight deadlines you must meet and can organize your case.
Bring a Sense of Clarity to the Complex Law
ERISA laws are some of the more complex laws that are more favorable to insurance companies than employees. An experienced long-term disability lawyer can use their knowledge of ERISA laws to navigate through the different laws associated with long-term disability claims. You can have more confidence during the process, knowing that a knowledgeable lawyer is aiding you in your fight for your benefits.
Force the insurance company to abide by the terms of your policy
While constructing your administrative record, your long-term disability lawyer can review the terms and conditions of your insurance policy and determine how the insurance company failed to abide by the regulations in the policy.
An experienced long-term disability lawyer is familiar with the technical language of insurance policies and can decipher what those terms mean. Long-term disability lawyers can also use examples of how insurance companies have abused their discretion by failing to comply with the terms of the policy.
Handle unfair evidence collection
From the moment you file your long-term disability claim, the insurance company will search for ways to deny your claim. They will resort to tactics you won't suspect, such as searching your social media accounts and taking video surveillance of you outside and engaging in physical activities. An experienced long-term disability lawyer can help you avoid the insurance company's use by advising you on how to move forward with the insurance company after seeking legal counsel.
Gather the ideal evidence for your administrative record
Your long-term disability lawyer can gather the best evidence to present in your administrative record. The insurance company will review that during your appeal. You may use the same evidence in a federal lawsuit.
An experienced long-term disability lawyer can collect the best evidence that illustrates why a court should overturn the denial of your claim.
Speak to a Houston long-term disability lawyer today
Being denied your long-term benefits can seem overwhelming. Let the long-term disability lawyers at J. Price McNamara ERISA Insurance Claim Attorney alleviate that stress by representing you in your fight for your benefits.
Call our office at (713) 300-0462, or submit our contact form for your Free Denial Review with a Houston long-term disability lawyer today. You deserve compensation when suffering from a long-term disability, especially when you have coverage through your employer.
Houston Office
2000 Crawford St
Suite 1649
Houston, TX 77002
Phone: (713) 300-0462
Fax: (225) 201-8313 (By Appointment)
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