Across the United States, 61 million adults live with a disability. While most of us think that it could never happen to us, the reality is that at some point in our lives, there is a substantial likelihood that we will be diagnosed with some type of disability. If that physical or mental health condition leaves you unable to work, a long term disability (LTD) insurance policy can provide a measure of financial security.
LTD policies provide a percentage of your monthly salary if you cannot work because of a disability that lasts for an extended period of time. Unfortunately, even if you faithfully pay your premiums for years, your insurance company may still wrongfully deny your LTD claim, delay paying your benefits, or end your benefits early. In these situations, a Philadelphia long term disability attorneys can advocate for you and help you get the benefits that you deserve.
Bross & Frankel is a Philadelphia law firm that is devoted to fighting for the rights of people with disabilities. With more than 90 years of combined experience, we understand how the system works — and put our knowledge to work for our clients. From an initial claim review to the final resolution of your claim, we will stand by your side and help you get the best possible result.
Understanding Long Term Disability Insurance
Long term disability insurance is a specialized type of policy that is often available through employers’ group plans. You can also buy it as an individual. Because it offers monthly payments of up to 50 to 60% of your salary if you cannot work, it is an important part of an overall financial plan.
If you become disabled and cannot work as a result, your LTD policy will provide benefits for anywhere from 24 months, until you can return to work, or up to retirement age. There is a waiting period (typically 6 months after you become disabled) to apply for these benefits.
For policies that were purchased through a group plan, the federal Employee Retirement Income Security Act of 1974 (ERISA) will govern the administration of the policy. Under ERISA, your insurance company must provide certain information to you and offer an appeals process. If you purchased your policy individually, then it will be governed by state law.
If your insurance company acts in bad faith or otherwise violates the law or the terms of your policy, you can file a lawsuit against it in either federal (for ERISA claims) or state court. Before doing that, you will need to exhaust the administrative appeals process with your insurer. Philadelphia long term disability attorneys can evaluate your LTD policy and counsel you on your rights under it.
Why Was My LTD Claim Denied?
Long term disability insurance is a vital part of a financial plan. Too often, however, insurance companies engage in tactics that make it difficult for policyholders to get benefits or to obtain the full amount of benefits that they are entitled to under the law.
Like other insurance companies, LTD insurers are in the business of making money, not paying out on claims. To maximize profitability, your insurance company may delay your claim, deny it outright, or end your benefits early without cause.
This can happen in a number of ways, such as:
- Denying your claim because of a pre-existing condition
- Denying your claim because you haven’t proven that you are disabled;
- Using the opinion of an independent medical professional to argue that you are still able to work;
- Terminating benefits at 24 months for certain conditions;
- Using surveillance to deny your claim;
- Arguing that you no longer meet the definition of disabled; or
- Stating that your disability is not supported by objective medical evidence.
Wrongful Denials of LTD Claims
Like all insurance companies, insurers who offer LTD policies are in the business of making money. In fact, some of the biggest insurance companies — like The Hartford — rake in billions of dollars in profit each year. These corporations don’t post these kinds of profits because they pay out on LTD claims, but because they look for ways to deny or minimize their liability for LTD claims.
Insurance companies use a number of tactics to achieve this goal, from terminating benefits early to delaying claims to denying claims outright. For example, an insurance company may ask to submit and resubmit documentation of your disability, pushing out a decision on your application for benefits for months or longer. They often employ their own teams of medical professionals, who will review your application and decide — without ever examining you — that you are not truly disabled or unable to work.
Other strategies for denying claims may include using surveillance to gather information about you in order to deny your claim, requiring you to undergo an independent medical evaluation to argue that you are able to work, or denying your claim on the basis that you have a pre-existing condition. An insurer may also exercise a clause in your policy to terminate benefits after 24 months or end your benefits because you no longer meet the definition of disabled under the policy.
One of the best ways to prevent this from happening is to consult with an experienced LTD lawyer as soon as possible. Many LTD denials are based on the terms and conditions of the insurance policy. An attorney can evaluate your policy and advise you on the best way to avoid a denial or an early termination of benefits.
If your claim is denied, you typically have a limited period of time to file an appeal with the insurance company. From there, you may be able to file a lawsuit in state or federal court for a bad faith or wrongful denial of your claim. A Philadelphia long term disability attorney can help you file an initial appeal, and then pursue a lawsuit if that appeal is unsuccessful.
What Is the Difference Between Individual Disability Insurance and an Employer-Provided Policy?
The main difference between a long-term disability policy that is purchased by an individual and one that is offered through a group plan is the law that will govern it. In turn, this influences what remedies are available if your insurance company acts in bad faith by unfairly denying your claim or terminating benefits early.
If you purchase a LTD policy directly from an insurance company (including through an agent, broker, or trade association), then the policy will be covered by state law. This means that if you have a dispute with the insurance company over your policy or benefits, then you can file a lawsuit in state court after exhausting the administrative appeal process.
In contrast, if your LTD policy was obtained through a group plan, then the federal Employee Retirement Security Act of 1974 Act (ERISA). ERISA sets forth specific rules for insurance policies offered by employers. If a dispute arises under an employer LTD plan, then your Philadelphia disability benefits attorney may file a lawsuit in federal court to enforce your rights.
How Long Does the Insurance Company Have to Make a Decision about My Claim?
The answer to this question depends on whether the policy was obtained through your employer or purchased individually. If you have a LTD policy through a group plan, then ERISA applies. Federal law provides that a claim should be approved or denied within 45 days of receipt of the claim, with an extension of up to 30 days if needed. The insurance company must notify the insured that additional time is needed, why it is necessary, and when a final decision will be made.
If the LTD insurance policy was purchased individually, then state law applies. Under the Pennsylvania Insurance Code, a decision on a claim must be made within 30 days of filing. However, if the investigation of the claim cannot be completed within that time, then this time period may be extended by 45 days, provided that the insurer provides written notice, an explanation for the delay, and the expected date of completion. There may be multiple extensions of this deadline.
If your insurance company fails to approve or deny your claim within these time frames, and has not notified you of the need for additional time, then you may be able to file a lawsuit against them.
What Type of Information Will I Need to Prove My Claim?
When you submit a claim for long-term disability benefits, the insurance company will require you to provide certain information or evidence to support it. The exact proof of claim requirements will depend on the policy terms.
You may be required to submit proof such as:
-That you are under the regular care of a doctor
-The day that your disability began
-Medical records that confirm your diagnosis
-How your disability limits your ability to work
-Contact information for any healthcare provider, hospital, or other institution where you have received treatment
-Your monthly earnings
Keep in mind when gathering evidence that it must prove two things: (1) that you have a disability; and (2) that this disability makes you unable to work. If you have questions or need assistance with filing a LTD claim, reach out to a Philadelphia LTD attorney.-
What Will an Insurance Company Do to Investigate My Claim?
An insurer may use a number of tactics to investigate your claim and determine if it is valid. Typically, this starts with asking you to sign certain authorizations so that the insurance company can obtain medical and financial records. The claims adjuster will then begin to review and analyze your medical and financial records.
The insurance company may also reach out to your employer to get additional information about your job, such as your duties, the hours that you work, and how long you have been employed in that job. In many cases, insurers will use other strategies to investigate your claim, such as:
-Performing a background check
-Requesting telephonic or in-person interviews
-Internet and social media searches
-Consulting with medical and financial experts
-Requesting that you undergo a medical examination
These tactics may sometimes cross the line and may be considered unreasonable. In this situation, your attorney can help you determine how to address these actions.
Considering an LTD Claim? We Can Help.
No one wants to be diagnosed with a disability or to be forced to stop working because of that disability. Yet for millions of Americans, this is reality. If you find yourself in this position, we can help, starting with a free claim review and continuing throughout the LTD claims process.
Bross & Frankel focuses our practice on disability benefits. We represent people throughout the Philadelphia area who are unable to work due to a physical or mental health condition, helping them get the benefits that they are entitled to under the law. To learn more or to schedule a free claim evaluation, call us at (215) 545-5990 or email us at any time.