Long-term disability insurance is different than Social Security Disability. Long-term disability policies are generally provided by employers although many individuals, especially professionals, may privately purchase a long-term disability policy. If you are disabled you may be able to obtain Social Security benefits that are separate from benefits from a disability policy from your employer or purchased privately.
Long-term disability policies that are provided by employers generally provide benefits for the disabled individual for two years if that person is incapable of performing the material duties of his/her own occupation. After two years these policies generally provide that an individual is disabled only if he/she cannot perform the material duties of any occupation to which he/she is suited by education and training.
These policies generally have a limitation of two years on benefits for a disability based on a psychiatric condition.
Privately purchased policies are generally "own occupation" policies solely, providing benefits to an individual if he/she cannot perform the material duties of that person's specific occupation.
Long-term disability companies frequently deny claims for long-term disability benefits. It is extremely important that physician records support the claim for disability and clearly document the disabling condition.
IT IS CRUCIAL THAT YOU ARE AWARE OF ALL DEADLINES AND TIMEFRAMES AS FAILURE TO TIMELY FILE AN APPEAL CAN FORFEIT YOUR APPEAL RIGHTS AS WELL AS POSSIBLY DAMAGING A POTENTIAL LAWSUIT.
APPEALING A LONG-TERM DISABILITY INSURANCE DENIAL:
Unlike with health insurance, an insured usually only has one appeal to the insurance company; there is no external review and no second level of appeal. THEREFORE, THE APPEAL MUST CAREFULLY ADDRESS ALL THE ISSUES, INCLUDING MEDICAL AND OCCUPATIONAL ISSUES. The appeal is generally what a court will consider if the case is litigated so it is crucial that all information is provided in the appeal.
If you are denied disability from your policy, or if your insurance company has notified you that it is discontinuing your disability benefit payments, you must appeal the denial. It is crucial that you have your physicians involved to address the reasons for the insurance company’s denial. Typically the company has used an outside physician who has determined that you are no longer disabled. However, there are critics who believe that these outside physicians lean toward denying benefits and do not consider the entire medical file.
It is very important that a physician be able to submit a letter addressing the insurer's reasons for denial and be able to document from the medical records why that denial is wrong.
It is also often critical to have an independent occupational assessment to determine the extent and scope of the individual's disability and what occupations the individual may be able to work.
SHOULD YOU USE AN ATTORNEY?
It is important to consider having an attorney involved from the beginning of the appeals process. Not only will he/she understand your rights but will be able to gather the proper information, work with your doctors, and present the case to the company or the external reviewer. IMPORTANT: If you do retain an attorney make certain heshe has experience in this area.
IMPORTANT: THERE ARE DEADLINES FOR FILING APPEALS AND CLAIMS IN COURT. YOU SHOULD CONSULT AN ATTORNEY ABOUT THESE TIME FRAMES AND YOUR RIGHTS.
APPEALING LONG-TERM DISABILITY INSURANCE DENIALS
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