When you are unable to work, you may need LTD benefits to maintain your financial security. However, insurance companies tend to deny disability claims, especially if your policy provides high-value benefits. Before you file a claim for benefits, you need to be well-prepared. Long term disability lawyer J. Price McNamara can help.
Eligibility for Long Term Disability Benefits
Insurance companies typically pay long term disability benefits, and your eligibility will depend upon the terms and conditions of your policy. Before you file for LTD benefits, you should get copies of your current Summary Plan Description (SPD) and Plan Document. LTD plans must set out their eligibility criteria and claim process in writing. The SPD will give you an overview of these issues, while the full Plan Document provides a comprehensive (and more formal) discussion of the plan’s criteria and processes.
While eligibility varies from plan to plan, there are some common requirements. Typically, to be eligible for LTD benefits you must:
- Complete a waiting period (from several months to several years),
- Have medical evidence that contains a clear and fact-based diagnosis, and
- Have work restrictions that prevent you from performing either your occupation or all occupations.
If there is any doubt that you meet your plan’s criteria, your claim will be denied. While a denial can be upsetting, do not assume that you are ineligible for LTD benefits.
Reasons for an LTD Denial
Long term disability claims are denied for many reasons. There may be a technical problem, such as a late filing or a short-lived disability. However, most LTD claims are denied for more nuanced reasons, including:
- Insufficient medical evidence,
- Lack of a clear diagnosis (or an unusual diagnosis),
- Disagreement about the severity of your condition and your ability to work,
- Concern about substance use or dependency,
- Questions about your credibility, or
- Non-compliance with insurance company requests (such as failure to complete forms or attend a medical examination).
Moreover, insurance companies frequently deny legitimate long term disability claims. If your claim is denied, contact a long term disability lawyer for assistance. An experienced lawyer will perform a detailed analysis of your claim, create a customized appeal strategy, and ensure that you follow your plan’s procedures.
Filing a Long Term Disability Appeal
The LTD process varies depending on whether you have an ERISA or non-ERISA plan. The Employee Retirement Insurance Security Act (ERISA) is a federal law that controls employee benefit claims. If your long term disability plan is employer-funded, ERISA typically applies. However, ERISA does not cover employee benefits offered by governments and religious organizations. If you have a personal LTD policy, it is a non-ERISA plan. If you need help assessing your plan, contact a long term disability lawyer for assistance.
ERISA Long Term Disability Appeals
In an ERISA claim, you cannot immediately file a lawsuit disputing the insurance company’s denial. Instead, you must exhaust your administrative remedies by filing an appeal with your plan administrator (typically the insurance company). In an administrative appeal, you must follow the procedures set out in your SPD and Plan Document. If you do not follow these procedures, your appeal will be denied.
It is important to provide all of your evidence at the administrative appeal level. Once the insurance company has issued a decision in your ERISA appeal, it is very difficult to submit additional evidence. For this reason, you must review the insurance company’s complete file and supplement it with any missing evidence (including medical records, vocational information, and other important data).
If the insurance company denies your administrative ERISA appeal, you may file a federal lawsuit. Filing deadlines may vary, depending on your plan. If you do not file a timely appeal, the federal court will dismiss your claim.
In a federal ERISA appeal, you will not have a jury trial. Instead, a judge or magistrate will review your claim and written arguments and issue a decision. Since these appeals are highly technical, consider hiring a skilled long term disability lawyer to assist you.
Non-ERISA Long Term Disability Appeals
In a non-ERISA claim, you may immediately file a lawsuit against the insurance company, appealing your denial. In most cases, your lawsuit should be filed in a state court. You may be able to request a jury trial and seek punitive damages if the insurance company denied your claim in bad faith.
Regardless of whether you have an ERISA or non-ERISA claim, it is important that you build the strongest case possible. This will involve a detailed analysis of your plan’s terms and conditions, your medical records, and vocational information. Many disabled individuals cannot do this on their own. A long term disability attorney can help you follow the correct legal procedures, build a compelling case for benefits, and maximize your recovery.
Consult an Experienced Long Term Disability Attorney
Long term disability attorney J. Price McNamara has over 20 years’ experience handling LTD and other insurance claims. Contact his office for more information.