Disability Insurance is a type of insurance policy that’s meant to protect an employee from the loss of income in the event that he or she is unable to perform their work and earn money due to a disability caused by an accident, injury, or illness. It provides a safety net to employees who are forced to miss time at work. You may have found that filing a disability claim can be an incredibly complicated and frustrating process. This becomes even more frustrating if your claim has been denied. Disability insurance companies know the rules and understand how the game isplayedand will use rules against you. Your insurer knows that you’re going through a difficult time in your life and you may not be able to fight them on your own. But the disability benefits attorneys at Stop Health Insurance Denial are here to help.
We understand the laws associated with contract law, bad faith insurance law, disability insurance, and other areas of the law that will help you win your case. Our attorneys are extensively experienced in handling disability claims, lawsuits, and appeals. We have helped thousands of people fight wrongful denials by the Social Security Administration and insurance companies. If you’ve been denied disability benefits or would like to learn more about your eligibility,contact Stop Health Insurance Denialto discuss your case and for assistance with all issues related to your claim.
Qualifying for Disability Coverage
The definition of disability is quite expansive and tendsto vary from state to state and from one insurer to the other. Disability may include any injury or illness that prevents an individual from performing their normal job. For instance, a person with a knee injury may not be able to carry on with their construction work. Unlike worker’s compensation, there’s no prerequisite for the injury to have occurred while at work. Actually, conditions such as elective surgery, pregnancy, and childbirth may qualify. It’s a common perception that a physical injury is a requirement for an individual to qualify for disability benefits. Quite the opposite, an individual with a mental health condition is just as eligible to get coverage as one with a physical condition.
Short-Term and Long-Term Disability Claim Denials
Cases involving disability insurance claims dominate the Employment Retirement Income Security Act (ERISA) litigation landscape. 65 percent of ERISA employee benefits litigation cases from 2000 to 2010 involve disability claims, according to the DOL. But even so, insurance companies looking to make profits by containing disability benefit costs are usually motivated to aggressively deny disability claims. Disability insurance is in most cases governed by federal law but that does not deter insurance companies from denying valid claims. How does this happen?
First, insurance companies draft a plan term that gives them complete discretion to interpret the policy language and determine whether a claim is valid or not based on the terms of the policy. This means that the same entity that is required by law to pay benefits decides whether your claim is legitimate. In many states, courts are obligated to give respect the insurance company’s decision unless the insurer abuses its discretion. In thiscase,the decision of the insurance company is only reversed if a policyholder is able to demonstrate that the insurance company’s actions capricious and arbitrary, which is a complex standard for claimants to overcome. All in all, disability insurers are in some cases able to deny benefits and get away with it by drafting plan/policy terms that are incredibly one-sided at the expense of the policyholders. Most states don’t have claimant-friendly statutes but since disability insurance companies are large national corporations, it becomes easier for them to make company-wide decisions on a national level. They decide claims with the perception that their decision to deny benefits will not be overturned by the court.
Insurance companies typically provide three reasons for denying disability coverage;
They may claim that the policyholder is not really disabled based on the insurer’s definition
The definition of “disabled” varies from one insurance policy to the other and this creates an opportunity for insurance companies to claim the policyholder is not disabled or is partially disabled and can, therefore,be able to perform certain duties of their work.
They may claim that the insured did not cooperate with the insurance company’s investigations
When a policyholder files a claim, insurance companies usually carry out investigations to determine if the insured qualifies for benefits under its interpretation of “disabled.” At this stage, they may ask for extensive documentation of the policyholder’s disability, tax returns, financial statements, and other related documents. Failure to comply may result in termination of the policy or denial of coverage.
They’ll try to claim that a change of occupation resulted in the claimant not being disabled
Even if an individual’s changes their occupation to better accommodate their condition, the insurer may use that to deny benefits if the transition is done before the claim is filed. Insurance companies tend to compare duties that an insured has held for the past years before the disability and before filing the claim. Insurance companies often deny benefits based onchangeof occupation.
It’s also a common practice for insurance companies to hire the same doctors and medical consultants, over and over. Some ofthese doctors review a claimant’s medical records and come up with a conclusion even without speaking to or examining the claimant or their treating doctors. It’s easy for them to spend a few hours reviewing a policyholder’s file and then write a boilerplate report that the claimant is not disabled. Insurance companies then point to and relyonthese reports to insulate themselves from a court finding that they acted in bad faith.
An insurance company is typically entitled a lot of information about your disability, your occupation, your income, and just any other information related to your claim. However, insurers have a tactic of trying to delay payments by asking for additional information and sometimes even claiming that they never receive the requested documents. Or they may even claim that you never provided them with enough information. When faced with such hurdles, an experienced disability insurance attorney can advise you what to do and can help you understand what does and does not constitute a proper and reasonable request. We help clients deal with improper requests from the insurer and also help them collect and submit the proper information that will improve the chances of winning a case.
Appealing Disability Insurance Denial
The insurance company should not have the final say when you’re seeking disability insurance benefits. The process should not end just because you’ve received a denial. A denial does not mean that you’re not disabled or you’re not eligible to receive benefits. Both Social Security disability and employer disability insurance allow you to appeal a denial, several times if necessary. Even a plan that you purchased individually should allow you to appeal a denial. Most policies governed by ERISA law requires that beforean individual filea lawsuit, they must first file an internal appeal with the insurance company, in accordancewiththe policy’s language. There are rules that must be followed regarding how the appeal should be filed and handled.
Most employer-provided disability insurance policies are governed by the federal Employee Retirement Income Security Act (ERISA). This is designed to protect the assets of Americans so that funds are there when they retire. However, ERISA also governs disability insurance that most Americans obtain through work. But then, ERISA has complicated procedural rules that policyholders are required to follow so as to preserve their appeals rights. Also, ERISA has very strict deadlines for filing appeals and insurance companies usually use them against claimants such that once the time limit has passed, the case is over. On the contrary, there are virtually no consequences if an insurer misses a deadline.
Whenever an insurance company denies a disability claim, they’re required to provide reasons (in writing) for doing so. You can also request copies, for free, of expert advice, records, and documents that were used in making the decision. It’s also important to understand that there are deadlines that apply and you should, therefore,study your denial letter closely. Some plans give claimants 60 days to appeal while others allow 180 days. A missed deadline could mean that you’ve waived your right to appeal.
At this point, it’s important to work with an experienced disability insurance attorney who’ll work with you and your doctor to gather the necessary evidence needed to prove the validity of your claim. To file a successful appeal, you’d want to:
Add any missing or incomplete medical records
Submit written opinions from your doctors
Consider further testing
Verify receipt of all documents you send to and receive from your insurer
If your insurer still decides to deny your claim even after you’ve filed an appeal, you may decide to file a lawsuit in court to challenge the decision. Note, only the information you submitted during the appeal will be considered by the court. This is why it’s paramount to work with a seasoned attorney who can help you draft an appropriate appeals letter and submit all the necessary documents in your favor early in the claims process.
Appealing Social Security Disability Insurance (SSDI) Denial
There are four levels of appeals for Social Security disability insurance, which must be exhausted in order:
Reassessment by the state agency that denied your claim
Hearing before an administrative law judge
Appeal Council review
Federal court review
You must appeal a denial for Social Security Disability Insurance in writing within 60 days from receiving the denial letter. When appealing, you’ll also want to ensure that you have as much supporting evidence as you can find to supportyourclaim. Our attorneys can guide you through the steps, ensure that you have all the importantdocumentsand that you file your appeal before the deadline elapses. You don’t have to make direct payments to an attorney. Instead, the attorney’s fees will be paid out of any past-due benefits the agency owes you.
What Your Insurer Does Not Want You to Know
ERISA rules are different fromregularcourt and insurance rules. If you bring a lawsuit against your insurer, the court will only look at the information you sent to your insurer before the final denial was issued. As such, you cannot submit more documents and records once your case goes to court. While your medical records are vital to this process, submitting your medical records alone will rarely win a disability insurance case. Additionally, you need specific documents showing the limitations and restrictions caused by your medical condition. The forms used by insurer known as APS (attending physician forms) are usually limited in terms of the information that the doctor can provide when assessing your restrictions and limitations in a way that will prove that you’re disabled. These forms are drafted by the insurance companies and in most cases, the choices of answers that can be given by your doctors don’t include options for individuals who are disabled. And if there are such options, they may not match up with the definition of being disabled in your policy.
Once an ERISA case goes to court, insurers usually argue that the court should allow them to win provided they’re reasonable or that they should get the benefit of the doubt. These are just some of the obstacles that a seasoned disability insurance attorney can help you avoid or fight against so that you’ll have the best chance of winning your case and getting the benefits you’re entitled to.
Insurance Company Tagging a Policyholder as Not Disable when Social Security Has Approved the Disability
You may still be denied benefits by your employer disability plan even if the Social Security Administration has approved you for disability benefits. The most common reason for this conflicting situation is the fact that the SSA and insurance companies don’t always observe the same definition of disabled. Only by going through your disability insurance policy will you understand the exact wording and definition of “disability.” The definition under your policy is what really determines whether the benefits are payable when you make a claim. Also important to note, the definition of disability in most long-term disability plans may change after the first 24 months. For instance, your insurer might pay long-term disability benefits for the first 24 months if you’re unable to perform your “own occupation,” which means the specific occupation that a policyholder was engaged in at the time they became disabled or unable to work. Most policies provided to lawyers, dental and medical professionals define “own occupation” as the specialty that an individual practices within their field.
After the first 24 months, your insurer’s definition of disability may change to where you only get long-term insurance disability benefits depending on the inability to perform “any occupation.” This is a different and difficult set of criteria to be approved for. While the definition of “any occupation” varies from one insurance plan to the other, it’s probably going to be in the lines of a person’s inability to perform the material and substantial duties of any occupation for which they’re qualified for depending on their education, training, work history, and experience. Many policies will also have an income threshold that must be met.
Your claim is likely going to be under your insurer’s microscope in the six months leading up to the transition from “own occupation” to “any occupation.” At this point, there will be an extensive review of your claim, with your insurer aiming to terminate benefits once the 24-months period is over. Having an experienced disability insurance attorney by your side during this process can mean the difference between successfully navigating the difficult transition with your benefits intact, or having your benefits terminated. Insurance companies usually try to make their stand here, and for this reason, there’s really no guarantee that your benefits will not be terminated at this stage. And even if an attorney is not able to prevent your insurer from terminating your benefits, they can challenge them to minimize benefits and also protect important evidence for the appeal or lawsuit.
Finding a Disability Insurance Denial Attorney Near Me
Disability insurance companies are large corporations whose goal is profit. It has become common practice for insurance companies to repeatedly deny legitimate claims as a way of containing payments and increasing profits. You purchased your policy and faithfully paid your monthly premiums believing that the policy will provide you with crucial income in case you became disabled. Unfortunately, you’ve suffered a disabling injury or illness but your insurer is now refusing to provide you with the coverage you paid for and deserve. But the good news is that you can fight back when your claim is denied.
At Stop Health Insurance Denial, we understand how important your claim is for you and your family, and how difficult it can be to navigate the disability claim process. We can help you in every step of the way, including submitting a claim, handling and submitting your claim, appealing a denial, and filing a lawsuit against your insurer. Our disability attorneys have helped clients pursue their claims with many of the major insurance providers. We can as well litigate your case against any insurer countrywide.
Call us today at 310-695-5241 or fill out our online contact formto schedule a free consultation with one of our attorneys. We can answer any questions you may have, protect your rights, and helpyou get the coverage you need.