What Happens When an Employee Goes on Long-Term Disability?

What Happens When an Employee Goes on Long-Term Disability?

Many workers who suffered an injury or illness that keeps them from working wonder what happens when an employee goes on long term disability?

It is a major achievement to get the insurance company to approve your claim for long-term disability. Few people successfully persuade the insurance company to grant them benefits in the face of their own financial interests.

Once you receive a benefits approval, the disability insurance company should start paying you monthly.

Your long-term disability benefits will pay you a percentage of your pre-injury earnings. You can expect to receive this money every month.

If anything does not go as expected, and you do not receive your rightful benefits, or the insurer tries to end your benefits prematurely, never hesitate to seek help from a long-term disability claims attorney.

Disability Benefits Are Not a Guarantee Even When Granted

Insurance companies hate writing checks. They view you and your monthly payments as a drag on their bottom line. Thus, you have to keep a wary eye on them so long as you receive their checks. They will certainly keep their eyes on you.

Claimants should prepare for insurance companies to use every tactic in the book to cut off their benefits. The disability insurance company will use the law to its own benefit, especially when ERISA governs your claim. You never know what an insurance company can and will do when money is on the line.

Although the Medical Leave Act, the Americans with Disabilities Act, and other federal and state laws are designed to protect you, insurance companies don't always play by the rules. That's why you must work with a skilled and knowledgeable disability attorney to hold the insurance company accountable and help you obtain your rightful benefits.

Insurance Companies Change the Rules After Two Years

One of the key milestones in any long-term disability claim is when you reach the 24-month mark. Every single insurance provider changes the definition of disability at this point. Even if you already received benefits, this is a dangerous time for you, as you can very well lose the benefits the insurer initially granted.

Your policy contains two different definitions of disability. To qualify for benefits, you must meet your policy's definition of disabled in effect at the time.

The definitions of disability are:

• For the first 24 months, you need to prove that you cannot perform the duties of the job that you had before you developed your condition.
• After 24 months, the standard gets much tougher. Then, to show that you are disabled, you must demonstrate you cannot perform any job.

Long-term disability insurance companies don't make it easy on you. An experienced disability benefits lawyer can level the playing field and help ensure you meet all the necessary standards. Your lawyer will advocate strongly for you throughout the process to improve your odds of getting the long-term disability benefits or short-term disability benefits you deserve.

Insurance Companies Do Not Want to Continue Paying You Indefinitely

You can maintain your disability benefits, but the insurance companies can (and often do) complicate matters. They might require you to attend an examination with a doctor the insurance company hires. They examine you in a whole different light, completely independent of your initial medical exams when you first qualified for benefits.

Insurance companies decide to terminate benefits for mind-boggling reasons. For example, in one case, an insurance company completely ignored a claimant's chronic long-term back injury when it decided to terminate benefits.

The claimant had a job with physical tasks. A functional capacity evaluation after two years found she could lift, carry, push, and pull certain amounts, but she experienced extreme pain when doing so. The insurance company ignored her pain and stopped her benefits. The claimant fought the insurance company and won, earning the reinstatement of her benefits.

You Can Expect Insurance Company Surveillance

The insurance company will subject you to surveillance while you receive benefits. There is too much money at stake for them not to. If you wonder whether the insurance company can invasively check in on you, the answer is yes.

The insurance company may check your social media accounts to see what you do in your private life. Do not think keeping your settings private will keep the insurance company from learning what you do. They have ways of building a case to terminate your benefits.

The Insurance Company May Even Have Someone Follow You

An insurance company can hire a private detective to follow you around. They can do that, too, so long as they are not trying to take pictures of you inside your home. The private detective can see what you do in your daily life.

If the insurance company believes that what you are saying is inconsistent with how you live, they will not hesitate to challenge you and stop benefits. Then, you have to fight them in court.

In the case described above, where the insurance company cut off benefits, they photographed the claimant running errands and getting lunch. They used that as preposterous evidence she could perform the duties of a job. They may make outlandish decisions to force you to fight.

You Can Appeal When the Insurance Company Takes Away Your Benefits

You may appeal the decision when the insurance company cuts off your benefits. The process of appealing depends on how you got the policy.

If you purchased the policy privately, you can sue the insurance company for breach of contract. A judge will review your situation to determine whether you are disabled and whether the insurance company violated your rights by stopping benefits. You may even sue the insurance company directly for bad faith if they had no reasonable basis whatsoever to stop your benefits.

Filing an Appeal Under ERISA

If your disability benefits come from your job, you must pursue a different route to file an appeal. Employee benefits are governed by a federal law called ERISA. On the surface, this law protects employee benefits. In reality, the law protects insurance companies.

First, ERISA requires you to appeal directly to the insurance company. You may think that appealing the decision directly to the company that denied your claim in the first place is hopeless. Indeed, most of these appeals fail, as the insurance company just wants to strengthen its own denial if your case goes to court.

However, you still need to actively participate in the process, assembling a high-quality appeal file for the insurance company to consider when it hears your case. You must put forth all of your evidence at this point because you cannot add any evidence to the appeal file once you submit it to the insurance company.

If your case ends up in federal court, the judge can review only what you submitted to the insurance company as part of the appeal. The court will only review whether the insurance company reached the correct decision. You do not have the ability or right to add any information to the appeal file after that point.

A Federal Judge Can Give an Objective Decision About Your Case

The real battlefield in an ERISA disability benefits case is the federal district court. If the insurance company denies your case, the judge will review your case to determine whether the insurance company made a mistake in terminating your benefits. The judge will issue an objective decision after reviewing your case without any of the same biases or financial motivations that prejudice the insurance company.

Get Legal Advice, Even When You Are Receiving Benefits

Hire a lawyer when you are already receiving benefits. You will encounter challenges while receiving disability benefits that you need help navigating. You can never trust the insurance company when they pay you benefits because they always look for a way to stop paying you.

When the insurance company asks you to attend a medical examination around the 24-month mark, get legal help. The doctor will ask you a series of questions, and your lawyer will explain how to deal with them.

Hire an Attorney for Your Appeal

If the insurance company terminated your benefits, immediately hire a lawyer to handle your appeal. You have limited time to appeal the termination of benefits and need a lawyer’s help to do so.

You Can Fight or Negotiate a Settlement

The insurance company may pressure you to reach a settlement agreement with them so they can clear your claim off their books for less than it is worth. Your disability insurance attorney will build a strong case for your full benefits.

Employers Have Responsibilities Too

Employers are required by law (specifically the Americans with Disabilities Act in the US) to provide reasonable accommodations to qualified employees with disabilities. This means making adjustments or modifications that allow disabled employees to perform the essential functions of their job. Examples include:

• Modifying work schedules 
• Providing assistive technology or equipment
• Making facilities accessible (e.g. ramps, accessible restrooms)
• Adjusting or modifying training materials
• Providing interpreters or readers

The accommodation must be reasonable and not cause "undue hardship" to the employer.

Consequences for Non-Compliance

Employers who fail to provide reasonable accommodations may face:

• Legal action: Employees can file complaints with the Equal Employment Opportunity Commission (EEOC) or sue in federal court.
• Financial penalties: Employers may have to pay compensatory and punitive damages, as well as the employee's attorney fees.
• Required changes: Courts may order employers to make necessary accommodations.
• Damage to reputation: Non-compliance can harm an employer's public image and ability to recruit talent.
• Lost productivity: Failing to accommodate employees can lead to reduced efficiency and output.
• Potential loss of federal contracts: For federal contractors, violations could result in loss of contracts.

If you return to work and your employer doesn't reasonably accommodate your disability, speak with a lawyer right away about your options to hold them accountable.

You Do Not Have to Pay Out of Pocket for a Lawyer

It does not cost you anything to hire an attorney out of your own pocket. You will not pay any retainer fee to the attorney when you hire them. Instead, you only pay them if you win your case. The attorney will not send you hourly bills during your case, and will not bill you for you for their time if you do not win your case.

The risks are far more pronounced if you do not hire an attorney. Then, the insurance company will try to push you around because nobody will protect you.

If your disability insurer tries to stop your benefits when you still cannot work, never wait to consult an ERISA disability attorney. They can assess the reasons for your benefits cancellation and develop a strong appeal strategy. Put your appeal in trusted hands for the best chance of continuing benefits.

Contact a Disability Benefits Attorney Today

If you're having issues obtaining long-term disability benefits or an insurance company has denied your long-term disability coverage, don't hesitate to get legal help. The attorneys at J. Price McNamara have decades of experience assisting clients with obtaining their rightful disability payments. 

If you have a serious health condition that affects your ability to work, we can help you properly apply for disability benefits or appeal a denied disability claim. No matter your needs or the issues you're experiencing, you can trust us to offer personalized attention to your case and aggressively pursue the best outcome possible. 

Contact us today for a free consultation and learn how we can assist you.