Frequently Asked Questions about Long-Term Disability Claims, Lawsuits, Appeals, and Settlements

 

Q. How do I qualify for long-term disability?

A. The terms of the long-term disability insurance plan or policy will set forth the requirement for qualifying for long-term disability. You may think that if you are hurt or sick that your income is protected. However, when you look at the details of your policy or plan, it may not provide the benefits you thought you had. It may, in fact, provide little or nothing at all.

If there is a long-term disability policy or plan, then you qualify for long-term disability benefits when the conditions set forth in the policy are met. There may be other benefits available if you become disabled, such as Social Security disability or Supplemental Security Income (which are government-provided benefits), and disability pension benefits (provided by a pension plan). 

Examine your disability policy or plan to see what is covered before you file a claim. An experienced long-term disability lawyer can help you interpret your plan documents.

 

 

Q. What medical conditions qualify for long-term disability?

A. You may apply for long-term disability benefits through an employer-provided or private insurance plan, based upon a number of medical conditions such as heart disease, cancer, anxiety, depression, lung cancer, degenerative disc disease, or Parkinson's disease. But insurance companies regularly deny such long-term disability claims, arguing that they are not long-term or otherwise don't qualify.

For a list of disabling medical conditions which a long-term disability attorney at The Martin Law Group can help you pursue long-term disability benefits, click here.

 

 

Q. How do I know if I meet the definition of disability in my policy or plan?

A. Just because you have trouble performing your job duties does not mean that you meet the definition of disability. Many policies and plans define disability as the inability to perform any occupation – not just your own occupation.

Some policies only insure or cover your inability to perform any part-time occupation working 25 hours or more per week. Such a job may not exist near you, and part-time protection is not much protection. You may need two years or more of benefits if you are disabled from your job. Unless you have a huge cash reserve, paying money for a policy that does not protect your income does little good. A long-term disability lawyer can help you interpret your policy.

If your disability policy or plan does not provide the benefits that you need, you may have other options.

If you purchased a private policy, you may be able to switch policies. If it is a policy or plan through your employer, you need to contact your employer's human resources or benefits department and ask them to search for a better policy or plan. Or, you may need to purchase your own private disability policy in addition to that benefit. A long-term disability lawyer can help you explore your options.

There may be exclusions to coverage even if you meet the definition of disability.

Some policies will exclude or severely limit coverage for certain disabling conditions such as back or leg pain, fibromyalgia, or chronic fatigue syndrome. Some policies limit coverage to only one or two years for conditions like a neuromusculoskeletal disorder, fibromyalgia, arthritis or chronic fatigue syndrome. Other policies may go further and exclude coverage for any pre-existing condition that contributes to disability. That exclusion is regularly abused by insurance companies.

Some policies exclude coverage for anything that is not “objectively verifiable.” Objectively verifiable may be defined as proof of disability from an x-ray or some other diagnostic test. Unfortunately, pain and many other conditions cannot be x-rayed.

Watch for policies or plans with these exclusions or limitations of coverage. Ask an experienced disability lawyer to help you determine what your plan covers.

 

 

Q. How do I file a long-term disability claim?

A. The process for filing a long-term disability claim will be set forth in your plan document. You may have been given a summary of it when you were hired or when your employer adopted the plan. It may have an outline of the claim procedure, but usually, you will have to get the entire plan from the plan administrator, which is usually the insurance company that provides the benefits.

You must follow all of the prescribed procedures in the plan in order to preserve your rights. Adhering to the rules at the early stages of your claim and any appeal can make the difference between success and failure in a subsequent lawsuit to enforce your rights.

 

 

Q. How long do I have to file a long-term disability claim?

A. Your long-term disability insurance plan or policy should state when a claim must be filed. The ERISA regulations (the federal regulations which apply to long-term disability plans provided by employers) regarding time frames and deadlines are very technical and rigid.

The benefits claim procedures are set out in federal regulations and provide as follows for long-term disability claims:

• • A long-term disability insurance company has 45 days to accept or reject your claim.
  • The insurance company can inform you within that 45-day period that it needs a 30-day extension for a good cause.
  • The company may request yet another 30-day extension during the first 30-day extension.
  • All in all, the insurance company may take up to 105 days to make a decision on your claim.
  • If the company requests information from you during the claim process, it may seek to prolong the 105-day period even more.
  • If your claim is denied, you must appeal or request a review within the time period in the policy or plan, which must be at least 180 days for a disability plan.

If your claim is denied, you should consult with a disability attorney as soon as possible to maximize your chances for a successful appeal. A long-term disability lawyer must make sure that your claim record is as complete as possible, as it will be the basis of any appeal.

A proper and complete claim file is critical. So, getting a long-term disability lawyer on board as soon as possible is important as the deadlines for doing so and perfecting an appeal are not long. Ultimately, your long-term disability claim record will be reviewed by a judge if you have to file an ERISA lawsuit because the insurance company denies your claim.

 

 

Q. Can my long-term disability claim be denied later?

A. This happens all the time. We have represented claimants who received benefits for over 20 years before their benefits were denied and stopped. You would think that this only happens when someone's condition improves, but that rarely happens. Sometimes insurance companies do this because they think they can get away with it. A new adjustor takes over, or the company is sold, and they want to show their boss how wonderful they are by saving money. Or, there is a concentrated effort by a new director of the department telling the adjuster to deny claims so they can increase profits.

Wrongfully terminating a long-term disability benefit is actionable. 

If a company wrongfully terminates long-term disability benefits, a court can make them pay the benefits they should have been paid to begin with. However, no punitive damages nor mental anguish damages are allowed. It doesn't matter how much grief they put anyone through. ERISA does allow attorney's fees, though they are not regularly awarded.

 

 

Q. What qualifies as long term disability?

A. Long-term disability is a private benefit that is governed by a contract (generally, a policy) that is purchased by an individual or someone on his or her behalf. When it is provided by an employer, it is regulated or governed by federal or state law, depending on the employer. Generally, employers do not have to provide this benefit as there is no federal or state law requiring it.

​If there is a long-term disability policy or plan, then you qualify for long-term disability benefits when the conditions set forth in the policy are met. There may be other benefits available if you become disabled, such as Social Security disability or Supplemental Security Income (which are government-provided benefits), and disability pension benefits (provided by a pension plan).

 

 

Q. How is long-term disability calculated?

A. The first step in calculating a long-term disability benefit is determining covered pay (or earnings), which is defined by the policy. It could be a set amount. If it is, that amount will be your benefit. However, the benefit provided by the majority of policies offered through the workplace is calculated as a percentage of covered monthly pay.

For example, the long-term disability benefits may be 60% of covered pay. Some policies do not include bonuses, overtime, or shift differential in covered pay. With the covered pay and percentage identified, the gross benefit is a simple calculation.

The policy may set a maximum benefit. If the calculated gross benefit is greater than the maximum benefit, the maximum benefit is the gross benefit.

The second step is determining any offsets that reduce the long-term disability benefit. Again, these will be defined by the policy. Some common offsets are Social Security disability benefits, retirement, pension benefits, wages in another occupation, or another long-term disability benefit. The gross benefit is reduced by all offsets. The result is the net benefit.

The policy may set a minimum benefit. It could be a dollar amount or a percent of gross benefit. If the calculated net benefit is less than the minimum benefit, then most policies require that the minimum benefit be paid.

There are other factors to consider, of course, such as the elimination period and the maximum benefit period. Again, these would be defined in the policy.

At the outset of most long-term disability cases, our law firm calculates an estimate of the benefit based on the information provided by the client. As ERISA disability attorneys, years of experience calculating benefits under an array of long-term disability policies allow us to give our clients a pretty good estimate of their long-term disability benefits.

 

 

Q. Does long term disability continue after termination?

A. The right to long-term disability benefits continues as long as you are eligible for that benefit and up to the point of the maximum benefit period, even when your employment is terminated. The policy will define the maximum benefit period. Most policies issued in the workplace have age 65, or your Social Security retirement age, as the maximum benefit period. The policy will also define when your eligibility for continued benefits otherwise ceases.

​If your benefit is terminated and your plan requires an appeal, it is critical that you protect your right to future benefits by appealing that determination within the time required. If you ignore that determination and fail to timely appeal, your right to future benefits may be lost.

If your benefits are terminated, you should seek advice from an experienced ERISA long-term disability lawyer as soon as possible.

 

 

Q. Is long-term disability taxable?

A. Whether long-term disability benefits are taxable is a difficult question to answer and depends on a number of factors. Generally, tax professionals advise that disability benefits from a disability insurance policy are considered income if your employer provided the benefit or paid for the coverage using your pre-tax dollars for the plan year when you became disabled, but that they are not considered income if you paid for the benefit yourself with after-tax dollars or through your employer with your after-tax dollars.

We are not tax professionals or tax advisors. However, we work with our clients to make sure that they receive sound advice from someone who is. And, we make sure that the advisor has all of the information that they need to give our clients good advice.

 

 

Q. Can long-term disability be garnished?

A. Long term disability benefits can be garnished if the plan does not have anti-assignment or anti-lien provisions. If it does, it still may be possible for the long-term disability claim administrator to be required by court order to pay money directly to an entity having a right of garnishment. Because most people deposit their benefit payments into a checking account, practically, it may not matter. Most creditors will garnish the bank account.

 

 

Q. How does long-term disability work with Social Security Disability?

A. Long-term disability is provided in accordance with its governing contract (plan or policy). Its terms will govern any impact of Social Security benefits. Social Security benefits are not reduced by long-term disability benefits, but many policies require that disability benefits be offset or reduced by any Social Security benefits.​

Social Security offsets can vary. Some policies only offset the individual's Social Security benefit, while others offset ALL Social Security benefits received by the family of the disabled person because of his or her disability. For example, a $3,000 long term disability benefit may be completely offset by $3,000 in Social Security family benefits. There may be ways around this result. For example, the policy may provide a minimum benefit.

It's always best to check with an experienced ERISA long term disability lawyer.

 

 

Q. Can I volunteer while receiving long term disability?

A. If you perform volunteer work that is in conflict with the restrictions and limitations in place due to your disability, the long-term disability provider may argue that you are capable of full-time employment (or part-time employment). This is true even though you only volunteer a few hours a week. Even if your volunteer work does not conflict with your disability restrictions, the fact that you are doing anything might cause problems with your long-term disability. There are usually ways to engage in volunteer work without jeopardizing your long-term disability. Before volunteering while receiving long-term disability benefits, you should obtain the advice of an experienced ERISA long-term disability lawyer.

 

 

Q. Can I work while receiving long term disability?

A. Some long-term disability plans have a partial disability provision that allows you to work part-time, even in your own occupation. Other plans have an earnings qualifier, meaning that you can work in your own occupation (or another occupation) without your benefit being affected so long as you do not earn in excess of a certain percentage of your previous pay.

You must be careful. Under some policies, working a few hours may be evidence that you can work, causing the termination of your long-term disability benefits. Call an experienced ERISA long term disability lawyer before engaging in any work while receiving disability benefits.

 

 

Q. Can I receive long-term disability for mental illness?

A. What is covered by a long-term disability plan depends on its terms and provisions. Generally, there is no requirement that a long-term disability plan covers mental illness or, if so, for how long. The majority of plans issued in the workplace that covers mental illness do so for only 24 months. Coverage for physical conditions, on the other hand, may continue for much longer periods. Some states have laws that prevent disparity between disabilities.

The mental health issue may be the result of a physical condition. For example, chronic pain can lead to depression. The real cause of the disability is chronic pain, not depression. So, even if a policy can properly limit coverage for mental health issues, the actual disability may be a physical condition.

It is important to obtain the advice of an experienced ERISA long-term disability lawyer as soon as any type of limitation is imposed on your benefit. For a full list of the medical conditions our clients have suffered and received benefits for, click here.

 

 

Q. What is an offset?

A. An offset is the reduction of the long-term disability benefit due to being paid by the receipt (or the right to receive) monies from another source.

Long-term disability insurance carriers and managers of claims departments are constantly looking for ways to make the company more profitable. One way is to push the boundaries of offsets provided in the plan.

A very common offset in nearly all group long-term disability plans is the Social Security disability benefit. If a long-term disability benefit is $3,000 and Social Security pays $2,000, then the long-term disability benefit is reduced to $1,000. If there is another offset, it can be reduced further. Many plans often contain ambiguous language that includes an offset for Social Security “or any other similar act or law provided in any jurisdiction.”

An experienced long term disability lawyer can help you figure out what offsets are proper and take action when the company makes improper offsets.

 

 

Q: Why should I hire a lawyer if my long-term disability benefits have been denied?

A: Hiring a lawyer can significantly increase your chances of successfully appealing the denial and securing the benefits you deserve. They have expertise in disability law and can navigate the complex legal process on your behalf.

 

 

Q: How do I know if I have a valid case for appealing my long-term disability benefits denial?

A: An experienced lawyer can assess the specifics of your situation during a consultation. They will review your denial letter, medical records, and other relevant documents to determine the strength of your case and advise you accordingly.

 

 

Q: What can a lawyer do to help me with my long-term disability benefits appeal?

A: A lawyer can gather necessary evidence, prepare a strong appeal, negotiate with the insurance company, and represent you in administrative hearings or court if needed. They will advocate for your rights and work towards securing the benefits you deserve.

 

 

Q: How much does it cost to hire a lawyer for a long-term disability benefits denial case?

A: Our initial consultation is an evaluation of your case and it is free. We will explain whether you have a case with which we can assist, and the arrangement for the fee and case expenses. No charge until we have an agreement with you.

 

 

Q: What if I cannot afford to hire a lawyer for my long-term disability benefit denial case?

A: Some lawyers offer free initial consultations to assess your case. Additionally, legal aid organizations, pro bono services, or disability advocacy groups may be able to provide assistance or refer you to affordable legal resources.

 

 

Q: How long does the long-term disability benefit appeal process take?

A: The duration of the appeal process can vary depending on factors such as the complexity of your case, the backlog of appeals, and the specific procedures of your insurance policy. An experienced lawyer can provide a better estimate based on the specifics of your situation.

 

 

Q: Can I handle the long-term disability benefits appeal on my own without a lawyer?

A: While it is possible to handle the appeal process independently, having a lawyer by your side can greatly increase your chances of success. They understand the nuances of disability law, can navigate the system efficiently, and advocate for your rights effectively.

 

 

Q: What if my long-term disability benefits are still denied after the appeal?

A: If your benefits are still denied after the appeal, your lawyer can discuss further legal options with you, such as filing a lawsuit against the insurance company. They will guide you through the next steps based on the specific circumstances of your case.

 

 

Q: Can a lawyer help me if my long-term disability benefits were denied by my employer, not an insurance company?

A: Yes, a lawyer can assist you if your employer denied your long-term disability benefits. They will review your employment contract, relevant policies, and applicable laws to determine the best course of action and advocate for your rights.

 

 

Q: How can I find a reliable lawyer for my long-term disability benefit denial case?

A: You can start by asking for recommendations from friends, family, or other trusted sources. Online legal directories and state bar association websites are also helpful resources to find qualified lawyers specializing in disability law. When selecting a lawyer, consider their experience, track record, and client reviews to make an informed decision.

 

Have questions? We'd love to help! We chose this area of the law because we enjoy assisting employees to receive the benefits they paid for and worked so hard for. You don't have to fight the insurance companies on your own. We're here to help. Call for a free consultation today.

We are here to help answer your questions on long-term disability insurance claims. For more information, contact us today to speak with an experienced ERISA long-term disability lawyer regarding your long-term disability claim or disability appeal.

The information presented in these Frequently Asked Questions (FAQs) should not be construed to be formal legal advice or the formation of a lawyer/client relationship; however, they should help to answer some of the questions you may have regarding your claim.