Some medical conditions require surgery, and paying out-of-pocket expenses can become a burden. You cannot work during recovery, so the financial burden worsens. However, you can often obtain disability benefits after surgery temporarily so you can focus on your recovery and not return to work before you should.
The benefits will cover a portion of your financial needs and can help with your overall recovery. However, obtaining benefits is not simple. You want the assistance of a disability claim lawyer to ensure you apply for and receive the appropriate benefits for your surgical recovery.
Who Can Get Benefits?
You cannot obtain benefits for cosmetic surgery, but you can for elective surgeries. Cosmetic surgery is exempt because insurance companies do not cover any procedures that reshape healthy tissue and are not medically necessary.
If you are undergoing any of these surgeries, you will need to have your finances in place without considering disability benefits:
- Nose jobs
- Cosmetic dental surgery
- Tummy tucks
- Vaginal rejuvenation
- Breast augmentation
In some cases, you can benefit from plastic surgery because the procedures help to reconstruct body and facial defects. These injuries or defects might result from an accident, illness, or congenital deformity, and surgery is medically necessary.
Your insurance might likely cover these procedures:
- Breast reduction because it causes back pain
- Excess skin removal causes infections and rashes
- Nose job when a person has trouble breathing
- Dental surgery due to trauma to the teeth
An attorney can help you look at your policy and determine whether your surgery qualifies for benefits.
Other Surgeries that Might Qualify
For surgery to make you eligible for short-term disability benefits, the procedure must be medically necessary. It must also be medically necessary for you to remain out of work during your recovery. Claimants need to present proof of both of these facts before they can receive short-term disability.
Some medically necessary procedures that might require you to not work and might qualify you for benefits include:
- Removal of a gallbladder or another organ
- Surgery to repair ACL tears, other soft tissue tears, or broken bones
- Open heart surgery
- Knee or hip replacement
- Cesarean section births
Of course, the list can go on, and it is best to check with a disability attorney if you are unsure whether your surgery is eligible for benefits. They can review your policy and inform you whether your situation should qualify for short-term coverage.
How Short-Term Disability Works for Surgical Recovery
Depending on the insurance carrier, you will have to undergo a waiting period, typically seven days. You do not get any benefits during that time and should plan for the lapse. If you will miss fewer than seven days of work due to your surgical recovery, you might not need to file a short-term disability claim at all.
If you get approved for benefits, you will receive a portion of your lost wages for the time you must be out of work. The amount and time of coverage will vary from policy to policy, and an attorney can ensure you are receiving the maximum disability insurance benefits you deserve. You want to ensure you have the full financial support available so you can focus on your physical rest and recovery.
To start the process, you need to file a claim with your short-term disability insurer. Each company has a different claims process, so make sure you follow the necessary steps in your policy.
As part of your claim, you must prove:
- Your surgery is medically necessary and qualifies for benefits under the policy
- Your surgical recovery requires you to refrain from working for a certain period following the procedure
An insurance company will not grant you benefits unless you sufficiently prove these two things. While it might seem straightforward, many people face obstacles when proving they should receive benefits.
You will need to collect and present evidence of your post-surgical condition as part of your claim. You should consult with your doctor to ensure you have a clear understanding of what to expect. The insurance company will heavily rely on medical documentation, which is the most crucial evidence in your claim. You need to concretely support your need to stay home from work during your surgical recovery to qualify for benefits.
Your physician is likely well-versed in the disability process, and they can offer assistance. However, you should work with a disability claim lawyer for the best results. Your attorney will know what insurance companies expect in a successful disability claim, and they can help you present the strongest possible evidence in hopes the insurer grants your benefits right out of the gate.
Short-Term Disability Claim Denials
When you apply for short-term disability independently, you can face a denial of benefits. Even if you feel certain that your surgical recovery qualifies for short-term disability coverage, the insurance company can shock you by denying your claim altogether.
You will receive a letter that says you do not qualify for benefits and tells you why and what to do next. The denial is not the final word, as you have the right to appeal the decision. The right to appeal is good news because you have a second chance at obtaining the benefits you need and are entitled to for your time away from work. However, when you have an employer-sponsored policy, the appeal process is strict, and you must follow it exactly for a chance of success.
A federal law called the Employment Retirement Income Security Act (ERISA) governs employer-sponsored benefits plans, including short-term disability coverage.
The law sets out procedures for appeals, including:
- You must first pursue an administrative appeal with the insurance company (that already denied your claim)
- If you need to escalate the appeal, you must do so in federal court
There are deadlines for administrative appeals, and if you miss yours, you will have to live with the insurance company’s initial denial. You should contact a disability lawyer as soon as you receive a denial of benefits so they can assess the timeline of your appeal.
Further, you can only introduce new evidence to strengthen your case and challenge the denial with the insurance company. Once the case goes to court, the federal judge can only review what you already submitted as part of your claim file. This means you need to present all information and evidence possible during your administrative appeal for the best chance of success. You want the assistance of an attorney during this process.
While a denial of short-term benefits can be discouraging and can increase the stress of your surgery, it is not the final say on your claim. Always seek legal help with the appeal process so you can prove you deserve short-term disability benefits following your surgery.
Ending Short-Term Benefits
Short-term disability benefits will end when your condition reaches a reasonably reliable physical condition. Sometimes, insurance companies try to stop your benefits too soon if an adjuster decides you can return to work.
If you believe your benefits ended too early, speak with a disability attorney immediately. A lawyer can review your situation and help prove to your insurance company that you need more recovery time and ongoing financial support from disability benefits.
Long-Term Disability Benefits for Surgical Errors and Injuries
You should seek short-term benefits for your surgery, but you never know what will happen, and it is best to know all the categories of disability coverage available. While surgery should improve your condition, mistakes happen, and you might have lasting injuries or complications. While you initially sought temporary help, you may need other financial options.
The key difference between short and long-term disability is the time when you receive benefits. The short-term covers you for a short time, typically between three to six months, with some policies offering benefits for up to one year.
Long-term benefits can last for years, contingent on your individual circumstances. If your surgery results in complications that will keep you from working for longer than your short-term benefits cover, you will need to file a claim for long-term disability coverage.
Workers’ Compensation and Disability Benefits
Since many disability claims result from workplace injuries, employers have programs to pay injured workers during their time away. Workers’ compensation covers medical care for the injury, wage benefits, death benefits, and vocational rehabilitation services. The employer pays these benefits, and the employee doesn’t make any payments toward the benefits.
Disability benefits are different because they can cover non-work-related conditions, though someone receiving workers’ comp might also need to apply for private disability benefits. The intersection of workers’ compensation and short-term disability benefits is a complex one, and you should discuss all of your options for financial support with a disability claim attorney.
Managing Your Finances During Recovery
Build your savings as much as possible from when you learn about your surgery to when you undergo surgery. When you get short-term disability benefits, the funds come directly to you after the elimination period. You will have full discretion on how to spend them, and you should make a plan to ensure you can cover all of your expenses and basic needs.
However, you only receive a portion of your usual wages. Your benefits might not cover all your expenses, so you must also budget for the difference. You should prioritize your living expenses and discuss your finances with your spouse or other household members. If your spouse takes unpaid FMLA leave to care for you, it might create additional financial stress you need to account for before your surgery.
Budgeting might not do enough, and you can work with creditors to postpone payments without penalty. You can also ask for a reduction of your bills during your recovery.
The more you can handle before your surgery, the better your recovery will go. When people have surgeries and can’t work or pay their bills, they often don’t focus on their health. That can cause them to go back to work before they are ready and worsen their condition.
Returning to Work After Short-Term Disability
After surgery, you will have time to heal and recover, but eventually, you will likely have to return to work, which can feel like a struggle. You must stay in contact with your employer during your time away to determine logistics and when it is time to return to work. The physical and logistical part is one element; there is also the emotional aspect of changing your routine.
If you took months off, the company might have seen changes during your absence, and your coworkers and bosses might have changed. You can prepare by reading your benefit plan and explainer. Also, having a good relationship with your boss helps you get back to work safely.
While some people can jump right back in like they never left, others require additional transition adjustments. Some people need more rest breaks during the transition. You can require a slower workflow or might need to bring medical devices to work.
Each case is unique, and you should always work with your employer and physician to ensure there is documentation of changes in your physical condition. Your return to work will look different than someone else’s, and you want the best chance of a successful return to work following surgery.
Speak to a Disability Claims Lawyer
When you must get surgery to better your health that requires you to take time off work, you need to find options to supplement the income you will lose during your recovery. Short-term disability is one important option, but there are many hurdles to getting these benefits. If you qualify for benefits, you want to fight for them, and legal help is highly beneficial in this situation.
When seeking short-term disability benefits, speak with a local disability claim attorney to discuss your options and protect your rights as a policyholder.
If you receive a denial of benefits, you should immediately contact a Baton Rouge disability law firm‘s attorney who can assess your options to appeal the decision. Your chances of receiving your proper benefits are often much higher with the right legal professional on your side.
Following graduation from Loyola Law School in New Orleans in 1990, Price McNamara served as a Federal Judicial Law Clerk to the Honorable John M Shaw, Chief Judge, United States District Court Western District of Louisiana.
Mr. McNamara founded J. Price McNamara ERISA Insurance Claim Attorney, and began putting his past experience to work for the injured and disabled clients he now represents against the insurance companies in personal injury and long term disability and other insurance disputes in both federal and state courts