If you’ve filed a long term disability claim and received a denial, it can feel like a crushing blow. You’re already dealing with the physical and emotional challenges of a serious illness or injury, and now complex legal process to get the benefits you need and deserve. In such situations, the expertise of a long term disability lawyer can be invaluable. But who exactly might need the services of such a professional? This article delves into various scenarios where hiring a long-term disability lawyer is essential.
Individuals Facing Denied Claims
When life takes an unexpected turn and a long-term disability arises, complexities of disability insurance claims can become overwhelming, first no need to take stress, everything is fine. You’re not alone. According to the Social Security Administration (SSA), in 2020:
- 65% of initial disability claims were denied (Source: SSA Annual Report, 2020)
- 83% of reconsidered claims were denied (Source: SSA Annual Report, 2020)
- 40% of disability claims were ultimately approved after appealing to an Administrative Law Judge (Source: SSA Annual Report, 2020)
Unfortunately, claim denials are all too common. According to the Council for Disability Awareness, about 34% of long term disability claims are denied on the initial application. Many of these denials are due to insufficient medical evidence, missed deadlines, or other technical issues that can be resolved with the help of an experienced attorney. Insurance companies often deny claims based on technicalities or insufficient medical evidence. If an individual believes their claim has been unjustly denied, a lawyer can review the case, gather necessary documentation, and file an appeal to ensure the claim is reconsidered.
Under the Employee Retirement Income Security Act (ERISA), which governs most employer-sponsored disability plans, you have the right to appeal a denied claim. However, the appeals process can be complex and time-consuming, with strict deadlines and documentation requirements. A lawyer can help you gather the necessary medical evidence, meet important deadlines, and build a strong case for overturning the denial.
It’s important to act quickly if your claim is denied. Under ERISA, you typically have just 180 days to file an administrative appeal with your insurance company. If that appeal is unsuccessful, you may need to file a lawsuit in federal court to challenge the denial. The sooner you involve a disability lawyer, the better your chances of success.
Common Reasons for Denied Claims
Even if you have a valid claim, technical errors or oversights can lead to denials. Some common technical reasons for denied claims include:
- Lack of medical evidence: Insufficient or incomplete medical records to support your claim.
- Missed deadlines: Failing to file an appeal or submit documentation within the required timeframe.
- Inconsistent or contradictory statements: Conflicting information in your application or during the appeals process.
- Failure to follow treatment plans: Not adhering to prescribed treatment or medication regimens.
- Insufficient documentation of work history: Inadequate records of your work experience, income, or job duties.
- Lack of expert testimony: Not having a medical professional or vocational expert to support your claim.
Remember, a claim denial isn’t the end of the road. With the right legal support and advocacy, you can fight back and get the benefits you need to protect your health and financial security.
People Dealing with Complex Medical Conditions
Certain medical conditions can be difficult to document and prove in the context of a disability claim.
Some examples of complex medical conditions that can lead to long term disability include:
- Chronic illnesses like multiple sclerosis, lupus, or rheumatoid arthritis.
- Mental health conditions like depression, anxiety, or PTSD.
- Neurological disorders like Parkinson’s disease or traumatic brain injuries.
- Cancer and other serious illnesses that require extended treatment.
- Chronic pain conditions like fibromyalgia or complex regional pain syndrome.
Chronic illnesses, mental health disorders, and invisible disabilities like fibromyalgia or chronic fatigue syndrome often require extensive medical records and expert opinions. A long-term disability lawyer can help by coordinating with medical professionals to compile a comprehensive case that accurately represents the severity and impact of the condition.
These conditions can be challenging to diagnose and treat, and they often involve a wide range of symptoms that can be difficult to document and prove to an insurance company. A disability lawyer who specializes in these types of cases can help you gather the necessary medical evidence, work with your healthcare providers to develop a comprehensive treatment plan, and advocate for your rights with the insurance company.
In some cases, you may need to undergo an independent medical examination (IME) or functional capacity evaluation (FCE) to prove the extent of your disability. These exams can be stressful and intimidating, but the expert attorney can help you prepare and protect your rights throughout the process.
Do you know:
- Chronic illnesses account for 7 of the top 10 causes of death in the US (Centers for Disease Control and Prevention, 2020)
- 1 in 4 adults in the US have a disability (Centers for Disease Control and Prevention, 2020)
- Medical conditions that are likely to result in long-term disability include:
- Musculoskeletal disorders (e.g., back injuries, arthritis) (Social Security Administration, 2020)
- Neurological disorders (e.g., multiple sclerosis, Parkinson’s disease) (Social Security Administration, 2020)
- Mental health conditions (e.g., depression, anxiety disorders) (National Institute of Mental Health, 2020)
- Cancer (National Cancer Institute, 2020)
Legal Precedents:
- Barnhart v. Thomas (2003): The Supreme Court ruled that the Social Security Administration must consider all relevant evidence when determining disability benefits (539 U.S. 20)
- Cleveland v. Policy Management Systems Corporation (1999): The Supreme Court ruled that an individual’s inability to perform a single job task does not necessarily mean they are not disabled (526 U.S. 795)
- Social Security Administration’s (SSA) Disability Evaluation Under Social Security: Provides guidance on evaluating disability claims, including those related to complex medical conditions (SSA Publication No. 64-039)
- Department of Labor’s (DOL) Employee Benefits Security Administration (EBSA): Provides guidance on ERISA regulations and long-term disability benefits (DOL EBSA)
It’s also important to keep detailed records of your symptoms, treatments, and limitations, as this evidence will be crucial in building your case for benefits. Expert attorneys can help you organize and present this evidence in the most compelling way possible.
Remember, if you’re dealing with a complex medical condition, you don’t have to go through the long term disability process alone.
Employees with ERISA-Governed Policies
The Employee Retirement Income Security Act (ERISA) governs most employer-provided disability insurance policies. ERISA claims are particularly complex, involving strict deadlines and procedural rules.
If you get your disability insurance through your job, there’s a good chance it’s covered by a law called ERISA. ERISA has a lot of rules and regulations that insurance companies have to follow, but let’s be real – they don’t always play by the rules.
In fact, a study by the U.S. Department of Labor found that nearly two-thirds of ERISA claims are initially denied. That’s a lot of people getting turned down for the benefits they need and deserve.
If you’re one of those folks, contacting the long term disability attorney can be a real lifesaver. They know all the ins and outs of ERISA and can help you file an appeal or even take your case to court if needed. They can also make sure the insurance company isn’t trying to pull any fast ones, like denying your claim without a good reason or dragging their feet on making a decision. Employees who have an ERISA-governed policy and face difficulties with their disability claim can benefit greatly from a lawyer who specializes in ERISA law. These lawyers understand the intricacies of ERISA regulations and can effectively navigate the legal process to protect the employee’s rights.
Those Facing Insurance Company Tactics
Where do I even start with this one? Insurance companies are businesses focused on profitability, which sometimes leads to tactics designed to minimize or deny payouts. Insurance companies have a whole bag of tricks they like to use to avoid paying out on long term disability claims. It’s enough to make your head spin! here are some common ways reported being used by these comapnies:
- Delaying tactics: This is a classic move. The insurance company will drag their feet on making a decision on your claim, hoping you’ll get frustrated and give up. They might ask for more and more paperwork, or say they need to “investigate” your claim further. I’ve even heard of cases where they’ve taken over a year to make a decision! Talk about adding insult to injury.
- Lowball offers: Let’s say the insurance company finally decides to approve your claim. Great, right? Not so fast. They might offer you a settlement that’s way less than what you’re actually entitled to. They’re hoping you’ll be so desperate for money that you’ll take whatever they offer. But don’t fall for it! A long term disability lawyer can help you negotiate a fair settlement that covers all your needs.
- Surveillance tactics: Believe it or not, some insurance companies will actually hire private investigators to spy on you! They’re looking for any little thing they can use to prove you’re not really disabled. They might take photos of you going to the grocery store or walking your dog, and try to use that as evidence that you can work. It’s a total invasion of privacy, and it’s just plain wrong.
- Misinterpreting medical records: This one really grinds my gears. The insurance company will take your medical records and twist them to suit their own agenda. They might cherry-pick certain things your doctor said and ignore others, or take things out of context to make it seem like you’re not as disabled as you claim. It’s infuriating, but a good lawyer can help set the record straight.
- Pressuring you to return to work: If you’ve been on disability for a while, the insurance company might start pushing you to go back to work, even if you’re not ready. They might say they have a “modified job” for you, or threaten to cut off your benefits if you don’t cooperate. Don’t let them bully you! A lawyer can help you stand up for your rights and make sure you’re not forced back to work before you’re able.
- Changing the definition of disability: This is a sneaky one. When you first signed up for your disability policy, it probably had a certain definition of what counts as a disability. But sometimes, insurance companies will try to change that definition later on, making it harder for you to qualify for benefits. They might say you have to be unable to do any job, not just your own occupation. It’s a total bait-and-switch, but a lawyer can help you fight back.
- Terminating benefits prematurely: Just because you’ve been approved for benefits doesn’t mean you’re in the clear. Some insurance companies will cut off your benefits before you’re ready to return to work, saying you’ve “recovered” even if you’re still struggling. They might use any excuse they can find, like saying you missed a doctor’s appointment or didn’t fill out a form on time. It’s so frustrating, but a lawyer can help you appeal the decision and get your benefits reinstated.
The sad truth is, insurance companies are in the business of making money, not paying claims. They’ll use all kinds of underhanded tactics to avoid paying out on long term disability policies. But the good news is, you don’t have to put up with it! A long term disability lawyer can help you fight back against these dirty tricks and get the benefits you deserve. Don’t let the insurance company push you around – stand up for your rights and get the support you need!
Individuals with Pre-Existing Conditions
Pre-existing conditions can complicate a disability claim. Insurance policies often have clauses that exclude or limit coverage for conditions that existed before the policy was purchased.
Let’s say you’ve got a health issue that you’ve been dealing with for a while, like diabetes or a bad back. You apply for long term disability, but the insurance company says, “Sorry, we’re not covering that because it’s a pre-existing condition.” What do you do?
Well, first of all, don’t panic. Just because you have a pre-existing condition doesn’t mean you’re automatically disqualified from getting benefits. In fact, a lot of disability policies have something called a “pre-existing condition exclusion period,” which means they won’t cover disabilities related to that condition for a certain amount of time (usually a few months to a year). But after that period is up, you should be good to go.
If your insurance company is still giving you the runaround, that’s where a long term disability lawyer can help. They can look at your policy and your medical records to see if the insurance company is playing fair. They can also help you gather the evidence you need to prove that your disability is legit, even if it’s related to a pre-existing condition.
Here’s a real-life example: a woman in California had been battling lupus for years before she applied for long term disability. The insurance company denied her claim, saying her condition was pre-existing. But with the help of a lawyer, she was able to prove that her lupus had gotten much worse and was now preventing her from working. She ended up getting the benefits she needed to keep her life on track.
A lawyer can interpret these clauses and argue on behalf of the policyholder, demonstrating that the condition either does not fall under the exclusion or is indeed covered by the policy.
Self-Employed and Freelance Workers
Self-employed individuals and freelancers typically rely on private disability insurance policies rather than employer-provided ones. These policies can vary widely in terms of coverage and terms. When a claim arises, the interpretation of policy terms can be contentious. A long-term disability lawyer can provide clarity and representation, ensuring that the policyholder receives the benefits they are entitled to.
Seniors and Near-Retirement Age Individuals
As individuals approach retirement age, the stakes of a denied disability claim can be particularly high. As we age, our bodies undergo natural changes that can increase the risk of developing chronic illnesses or injuries. If you’re a senior or nearing retirement age, you may face unique challenges when applying for long-term disability benefits.
- Age-related health issues: Seniors are more likely to experience age-related health issues, such as arthritis, Alzheimer’s disease, or heart disease, which can impact their ability to work.
- Longer waiting periods: The Social Security Administration (SSA) has a five-month waiting period before disability benefits can be paid out. This can be a significant challenge for seniors who may be living on a fixed income.
- Complex medical histories: Seniors often have complex medical histories, which can make it difficult to navigate the disability claims process.
- Retirement plans impacted: Long-term disability can impact retirement plans, such as pension benefits or Social Security benefits.
Do you know:
- The average monthly disability benefit for a retired worker is $1,277 (Social Security Administration, 2021)
- 2 in 5 Americans aged 65 and older have a disability (Centers for Disease Control and Prevention, 2020)
Conclusion
Navigating a long-term disability claim can be daunting, especially when faced with denied claims, complex medical documentation, or insurance company tactics. In these scenarios, a long-term disability lawyer provides essential support and expertise, ensuring that individuals receive the benefits they deserve.