Short-Term & Long-Term Disability

Employer or Private Insurance

Employer-provided policies may be governed by the federal Employee Retirement Income Security Act (ERISA), which has strict and complex rules for how and when to file a claim or appeal the denial of one. Privately purchased policies are not subject to ERISA; they are administered in accordance with the contractual terms of the policy.

Like Social Security Disability claims, the applicant must prove they are medically unable to perform their job, but the standard for doing so is typically easier to meet for short-term and long-term disability insurance. The claimant need only prove they cannot perform their regular occupation and age is not a factor. The Social Security Administration, by contrast, holds younger applicants to a stricter standard than older individuals.

Timing

Policies differ, but most require a six-month waiting period before long-term disability payments commence, and most provide payments until the claimant reaches the age of 65.

However, at any point until that time, the insurance company is permitted to request a review of the claim to evaluate whether the disability has changed or lessened in severity. If their medical experts determine that is the case, they will immediately deny the claim and discontinue payments — unless the claimant successfully sues to overturn that determination.

The definition of “disabled” will be established in the insurance policy, but generally policies define it as being unable to perform a regular occupation.

Denied Claims

Claims administrators may be employed by the insurance company and many deny first time claims even if they are justified. Reasons given for denying a claim include (but are not limited to):

• Insufficient medical evidence (such as a lack of regular medical treatment, adequate records, or a doctor’s statement)
• Failure to meet the policy’s definition of disability
• Video surveillance by the insurance company that conflicts with the claim
• Missed application deadlines

Appeals

Policyholders have a right to appeal a denied claim and any determination that was made in that denial. There are strict deadlines to file appeals, however. Under ERISA and many private policies, the appeal must typically be filed within 180 days.

If the appeal is also denied, the policyholder can file a lawsuit in federal court. There is no right to a jury trial in these cases; a federal judge will review the basis for the insurance company’s decision as well as medical expert opinions and information presented by the policyholder rebutting it. The judge will decide whether there was a rational basis for denying the claim or not.

Legal Advocacy

The initial claim process for short-term and long-term disability insurance, any appeals, and federal lawsuits are delicate, complex, and challenging undertakings, particularly for an individual already suffering from a medical setback. Insurance companies are well resourced organizations that vigorously defend their economic interests.

Policyholders need equally capable legal support in the face of such obstacles. Pond Lehocky helps short-term and long-term disability claimants build their case by obtaining all the necessary medical information and expert opinions.

Furthermore, professional legal guidance can help policyholders if their benefits are wrongly terminated, their claim is delayed without cause, or if they received a settlement that is not commensurate with the level of disability or unfairly low.

Legal Fees