FAQs

When Must I File My Claim, and How Do I Start?

As soon as you suffer an injury or illness that causes a short- or long-term disability, you must notify the insurance company that you will no longer be working and intend to file a claim. Many insurance policies include a “proof of loss” provision, requiring claimants to notify the insurance company of their disability and that you plan to file a claim within a particular time – usually 30 to 90 days. If you do not provide notice within the proof of loss period, your insurance company may argue they were prejudiced by the delay, as they were unable to assess your condition at the onset of the disability. For the most part, you want to notify your insurer as soon as possible to let them know you intend to file a claim.

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What Role Does My Physician Play in a Long-Term Disability Insurance Claim?

Your doctor plays a vital role during the claims process, and he/she could be the difference between the success or failure of your claim. It can be complicated to challenge any decision reached by an insurance company, primarily when they use your own doctor’s opinions. For this reason, your doctor must understand what it means to be “disabled” under your policy. We will work with your doctor to ensure that he/she understands the importance of his/her role in the claims process and that all medical forms are prepared correctly.

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Do I Have to Suffer a Loss of Income to Collect Disability Income Payments?

This will depend on your policy. Under some policies, you do not have to have an income loss to qualify for disability benefits. In these cases, you need to prove yours prevents you from performing your occupation’s substantial and material duties. Under other policies, if you are only residually or partially disabled, rather than totally disabled, you generally must suffer a percentage loss of pre-disability income to receive payments. In claims of total disability, your eligibility for benefits is usually determined by the loss of ability to perform your work duties. If your claim is residual, your eligibility for benefits is also related to income.

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Why Has My Insurance Company Denied My Claim for Disability Benefits?

There are many reasons why an insurance company may deny your claim for disability benefits. However, many companies routinely use the same few reasons to deny claims. The most common reasons that insurance companies deny disability claims include:

• Lack of Objective Medical Evidence: If your disability cannot be detected by an X-ray, MRI, or laboratory test, many insurance companies will deny the claim, alleging a lack of evidence to prove your condition. They will have their in-house doctors review your records and deny benefits contending that you are not totally disabled under the policy’s definition of “disability.”
• Coverage Issues: Insurance companies may deny benefits based on coverage issues, which include problems that arise during the application or enrollment process. They may also allege that you had a pre-existing condition that prevents coverage.
• Allegations of Improved Condition: If your claim has previously been accepted, your insurance company may suddenly terminate your benefits, alleging that your condition has improved enough for you to return to work. They may base this decision on an improvement they see in your records, or surveillance, or on an examination of you that they requested.
• Change of Definition From “Own Occupation” to “Any Occupation”: The insurance company may terminate benefits after the expiration of the “own occupation” time, which frequently occurs after benefits have been paid for 24 months. At the change of definition, the insurance company may claim that you are well enough to perform some job and not disabled under the “any occupation” definition, even if you are still unable to fulfill your previous job.

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I Just Received a Letter Denying My Benefits. Am I Required to Appeal Before Filing a Lawsuit?

If you have an employer-sponsored plan, you must go through the insurance company’s internal appeals process before you can file a lawsuit. There is often a time limit to doing so, so make sure you appeal before this time expires. Many of our clients contact us as soon as their claim is denied, as we can help you build a strong appeal that may reverse the insurance company’s decision. If the appeal is finally rejected, your only option is to file a lawsuit, which we can assist you in doing.

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What is the Difference Between a Disability Insurance Policy Provision Insuring One’s Own Occupation versus Any Occupation?

Many insurance policies have an “own occupation” provision, which means that the policy will pay monthly disability payments provided that you are unable to perform the duties of the job you held before becoming disabled. Under many policies, this “own occupation” coverage is offered only for a limited time, usually 12 or 24 months. This means that once the “own occupation” period has expired, your benefits will be terminated unless you prove that you cannot perform “any occupation” for which you are reasonably qualified.

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What is ERISA?

ERISA is an acronym that stands for the Employee Retirement Income Security Act of 1974, a federal law passed by Congress. While this law was meant to protect employee benefits and create standardized laws for governing these benefits, it has developed into a more employer-friendly law. That makes it more difficult for employees to obtain their benefits. ERISA regulates most employee benefits offered by employers, including disability, life, health insurance, and retirement benefits.

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What is the Standard of Review and How Does It Affect My Claim?

The Standard of Review is the method that a court uses to decide a case. There are two types of review – de novo and abuse of discretion. All benefit claims are reviewed using the de novo standard unless the plan documents state that the administrator has the discretion to determine the claim’s outcome. In cases where the administrator is given discretionary authority in the policy, the court must review the claim using the abuse of discretion standard.

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What Are the Different Types of Review?

As stated above, the two types of review are de novo and abuse of discretion. The standard of review which applies to your case will depend on the language in the plan documents. If you are unsure of your plan’s details, our team can take a look at the details of your plan documents and determine which review process governs your claim. To give you a better explanation of the differences between these two types of review, we’ll go over each type in more detail below:

• De Novo: This type of review occurs when a court takes a new look at a case, paying no attention to the decision the insurance company previously made in denying benefits. De novo reviews are the type of court cases you most commonly see on television. Witnesses are summoned to court to give testimony. A judge or jury uses this testimony and evidence to make a decision.
• Abuse of Discretion: If your policy includes language that gives the administrator discretion, then the insurance company’s denial of benefits will only be overturned if the court finds no reasonable basis for the denial decision.