Imagine that you suffer an injury, or experience the onset or exacerbation of an illness, that makes it difficult for you to do your job. You visit your doctor who informs you that, due to your condition(s), you cannot work. Worse, you may never be able to return to your prior occupation, because the condition(s) from which you suffer – whether mental or physical – will likely continue to prevent you from performing the occupational responsibilities of your job.
The news that you cannot work due to a medical condition is devastating for a number of reasons. You must stop your life’s work. You may have a family that depends on your income to survive. The repercussions can go on and on. So you must ask yourself, what do I do? If you have a long-term disability insurance policy or you are a participant in your employer’s long-term disability plan, you may have long-term disability insurance coverage. If you are disabled, you must promptly apply for benefits; and there are a few essential things you should do/consider before placing your claim with the insurer.
1. First Look at Your Insurance Policy/Plan. It may sound obvious, but we receive many calls from disabled persons who know they cannot return to work and need to file an disability insurance claim, but they have not reviewed or even obtained a copy of their policies/plans. The terms of the insurance policy/plan should set forth the monthly benefit you receive, any preconditions to your receipt of those benefits, policy exclusions to coverage, the duration that your benefits will be payable, the “elimination period” for your policy and other crucial information that should be reviewed before filing a claim for long-term disability benefits.
2. Are There Any Deadlines For Filing A Claim? Yes. You should review your policy/plan to determine your time deadline within which to submit your long-term disability claim. A late claim may be denied by the insurer, even though you might otherwise be entitled to benefits.
3. Benefit Period Limitations. Disability policies/plans require payment of monthly disability benefits for the period during which you are disabled. Your Benefit Period may range from two years to lifetime, and is generally set forth in the policy/plan. You should review this information, as it will likely impact certain life-planning decisions you’ll be required to make.
4. What Type of Medical Proof of My Disability Is Required? It is paramount to your disability claim that you provide your carrier with proper medical evidence. It is insufficient to submit a doctor’s statement that merely indicates that you are “completely disabled” or “cannot return to work” without further information and documentation. It doesn’t matter whether you are bedridden or hospitalized; if you do not submit the appropriate medical evidence to the insurer you, in all likelihood, won’t get your benefits. To determine what medical evidence is appropriate, you must look at the terms of the plan/policy. There may be, for example, a requirement for “objective medical evidence,” which includes, for example, MRIs, CT Scans, blood tests, X-rays, and/or clinical physical examination findings by your doctor. Whatever the requirement under your policy/plan, be sure you are aware of it, understand it, and communicate that requirement to your medical providers who, inevitably, will be originating the medical evidence upon which the success of your disability insurance claim will depend.
5. Is My Medical Condition Covered? Plans/Policies often exclude certain condition(s)/injuries from coverage. For example, policies/plans typically do not cover any disabilities caused by, contributed to by, or resulting from, intentionally self-inflicted injuries or participation in a crime. We have also seen certain plans that exclude conditions that are based solely upon self-reported information and cannot be proven by recourse to objective evidence (e.g., Chronic Fatigue Syndrome). However, we have also met disabled persons whose benefits have been wrongfully denied because an insurance company demanded “objective evidence” of disability even though no requirement for so-called “objective evidence” is contained in the policy.
6. Limited Periods for Certain Mental and/or Nervous Conditions. Many plans/policies have a limited benefit period (often 24 months) for disabilities caused by a mental-nervous condition. The specific wording of a mental-nervous limitation is crucial. For example, some policies/plans limit the benefit payout period for disabilities caused by a mental-nervous condition while others limit the benefit payout period for disabilities that are “contributed to, in any manner, by” a mental-nervous condition. The distinction is an important one, and you should understand it before filing a claim. In the past, we have been successful in proving that psychiatric illnesses generally considered to be “mental nervous conditions” are actually physiological in nature notwithstanding their identification and categorization under the DSM IV and V.
7. Should I Call My Insurer and Ask For Advice? Calling an insurer to request advice implicates significant issues of concern. Remember, insurance companies are for-profit businesses. They generate higher earnings by denying claims than by paying them. Accordingly, one must be very careful in contacting the insurance company and asking for advice. An alternative to calling the insurer is contacting a legal professional who can help you through the process. There is too much riding on the approval of your claim to leave it up to the insurer, whose financial interests are diametrically opposed to yours. It is advisable to contact a disability insurance lawyer before you decide to file your claim, to help guide you through the claim determination process (whether at Hiller, PC or another firm that specializes in this area).
Disability Insurance plans/policies are complex documents with countless cross-references, definitions and legal implications. Understanding the complexities of your plans/policies requires a keen understanding of the legal significance of the terms of your disability insurance policy or plan. At Hiller, PC, we advise our clients on the complexities of their plans/policies. We work with our clients to ensure that their claim is approved, or, if it is already approved but you are concerned that the insurer is re-evaluating your claim, that the insurer continues to pay your claim and keep you “on benefit.” If your claim has already been denied, we work with you to reinstate your benefits, whether by means of an administrative appeal (if you’re covered under a group policy) or by resource to litigation if it is necessary.
