Filing for and maintaining your long term disability insurance benefits can be a confusing and complicated process. Wherever you are in the process, there is a lot to consider.
With so much at stake, it is essential to handle your disability claim correctly to avoid delays, obstacles, and benefit denials. Careful strategic planning is key.
At Riemer Hess, we鈥檝e been helping individuals win and maintain their disability benefits for over 25 years. Our NYC ERISA long term disability attorneys are well-versed in all aspects of long term disability claims. Below you will find important information regarding the best strategies to filing, appealing, and protecting your long term disability claim.
Having a plan before exiting your career can help prepare you for the disability claims process and increase your claim鈥檚 chances of approval. At Riemer Hess, we have successfully guided scores of clients through the process of leaving work to filing for disability. Below we鈥檒l answer common questions about how to plan your work exit.
First, let鈥檚 explain: What is ERISA? What is long term disability?
Disability benefits can come from different sources. Social Security Disability benefits are provided by the government to people with disabilities. When we refer to long term disability in this article, we refer to long term disability insurance from private companies.
Long term disability insurance is typically received in two ways:
You may also have multiple LTD policies, of either or both types.
Long term disability (鈥淟TD鈥�) insurance through your employer, also known as a group plan, is generally treated as an employee benefit. Because of this, employer-provided LTD plans are regulated under the federal Employee Retirement Income Security Act of 1974 (ERISA). These policies are subject to the provisions of ERISA.
Learn more about LTD disability insurance 糖心直播
Before anything else, review your ERISA long term disability (鈥淟TD鈥�) insurance policy. Your policy is key to planning a successful transition to disability. See the next section for more on understanding your disability insurance policy.
Once you have familiarized yourself with your LTD policy, obtain copies of your medical records from your treating doctors. Your insurance company will require medical evidence of your disability before approving you for benefits. Your doctors' support is essential to your disability claim. Not only will their records be necessary, but you may need them to provide supportive letters to your insurance company and/or employer.
With your insurance policy and medical records in hand, you can better evaluate whether you have the appropriate evidence to support a disability claim. For example, after reviewing your records, you may see you should increase your frequency of treatment or communicate symptoms not recorded in your treatment notes.
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Understanding your long term disability insurance policy is critical to planning your claim. Your policy contains the terms you must meet to qualify for disability benefits. This includes the definition of disability, the occupational standard, and the elimination period, among other requirements.
Your policy's definition of disability will determine what standard you must meet to qualify as "disabled." An "own occupation" definition means you only must prove you cannot perform the duties of the occupation you were in when you became disabled. An "any occupation" definition means you must prove you cannot perform any occupation reasonable for your education, training, and experience. Your policy's definition of disability will determine the framework for your disability claim.
Our guide to disability insurance policies provides useful information on understanding the terms of your policy.
Learn more facts about filing for ERISA Disability Benefits
If you are fired or terminated before taking disability leave, your opportunity to file a long term disability claim may be in jeopardy if your coverage is provided through your employer ("group" coverage).
Understandably, many people with serious medical conditions are hesitant to leave their careers for long term disability. Many people attempt to continue work past the point of being able to successfully execute their job duties. It may be difficult to gauge your condition鈥檚 impact on your performance, or you may struggle with the uncertainty of the long term disability process. However, attempting to continue work when your performance declines due to your health issues can backfire.
Filing a long term disability claim if you've been terminated from your job is possible, but it will be an uphill battle if you have group coverage. Your long term disability insurance company may deny your claim by arguing you are no longer covered by your policy as of your last date of employment. Most policies have provisions stating they are only active as long as you are working for your employer.
For you to have an eligible disability claim with group coverage, you must generally demonstrate to your insurance company that you became disabled before your last date of work. This means providing medical evidence of your disabling condition that predates your last day on the job. We recommend our clients in this predicament obtain a written statement from their treating doctor stating the history, progression, and extent of their disability. Further, if you have evidence from your employer of your declining performance (such as a poor annual review), this can potentially substantiate your disability claim.
Other factors may complicate your right to file for group LTD benefits. For example, if you have signed a severance agreement, you may have waived your right to file a claim.
We always recommend consulting with an experienced ERISA attorney rather than filing a claim on your own. An experienced attorney will be able to review your circumstances and determine the best strategy to filing a successful disability claim.
Learn more about filing an LTD claim if you are fired or laid off
People on disability leave are granted certain job protections. The federal Family and Medical Leave Act (FMLA) provides up to 12 weeks of unpaid, job-protected medical leave per year. However, not all employers are subject to FMLA. Your company must have a minimum of 50 employees, and you must have worked for a certain amount of time and hours to qualify. Other exemptions may apply.
Your state might provide additional job protections above and beyond FMLA. Always check to see what your state might offer.
Many states in the U.S. have at-will employment, meaning an employer can legally terminate an employee for any non-discriminatory reason. People with disabilities are classified as a protected class. You potentially would have a wrongful termination case if your employer terminated your employment while you were on disability.
This area of law is very specific and dependent on many individual factors. If you have been fired while on disability leave, or fear you will be, we strongly recommend that you speak to an attorney who can explain your rights and options.
Learn more about if you can be fired while on disability
One mistake on your application could jeopardize your disability benefits. Getting your initial claim application right will save you time and money.
Your long term disability insurance application creates the groundwork for your disability claim. Getting your disability benefits approved necessitates meeting the requirements of your insurer.
At Riemer Hess, we鈥檝e honed a successful strategy for getting our clients鈥� disability claims approved. Below we鈥檒l outline a few important strategies when filing a long term disability claim.Click the links below to explore more in-depth strategies for filing an LTD claim.
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In order to receive disability benefits, your insurance company will require you prove that:
Not only must you provide your insurance company with medical evidence of your disability, you must also explain why your condition limits you from working.
Your insurance company evaluates your occupation in a number of ways. First, they will categorize your occupation in one of the following categories: sedentary, light, medium, or heavy. Your occupation鈥檚 category depends on how physically demanding your duties are.
Your functional limitations (i.e. inability to perform your work) can be exertional or non-exertional. Exertional limitations include sitting, standing, walking, etc. Non-exertional limitations range from manipulative (problems using your hands/fingers), mental (issues with concentration, focus, etc.), postural (inability to stoop/bend/etc.), and more.
It鈥檚 important to understand how your insurance company will categorize your occupation. For example, if you are a senior level accountant, your job would likely be considered sedentary. You will need to provide proof that your medical condition impacts your ability to perform your job. If your medical evidence only shows you cannot walk long distances or lift heavy objects, your insurance company could deny your claim. Your evidence must show you have non-exertional limitations.
Learn more about how functional limitations can disable you from your job
Check out our Vocational Evidence section below for more on how you can prove your work restrictions and limitations to your insurance company with evidence.
When filing an LTD claim, your insurance company may want to interview you. Don鈥檛 be too alarmed if this happens 鈥� it is not necessarily a red flag. In fact, approximately half of our clients face an interview request during the claims process.
However, you do want to be prepared for any interview. Your insurance company will either request a 鈥渇ield鈥� interview (conducted in-person) or a phone interview. Common subjects for these interviews include a timeline of your disability, your symptoms, why you left work, and plans for the future.
You should always be truthful during these interviews. However, be careful in how you answer their questions. Insurance companies may ask broad questions. Do not be afraid to provide full context or elaborate if needed.
For example, one common question from insurance companies is: 鈥淗ow do you spend a typical day?鈥� This is a trap if you have variable symptoms. If your symptoms fluctuate, you can explain to your interviewer that there are no "typical" days -- you have good and bad days.
Having an experienced ERISA attorney is very helpful in this situation. They will help prepare you for questioning, monitor the interview, and object to any inappropriate questioning.
Learn more about preparing for your interview with the insurance representative
When filing a long term disability claim, your insurer may schedule you for an Independent Medical Examination (also known as an 鈥淚ME鈥�). An IME is an examination done by a physician of the insurer鈥檚 choosing. The IME physician will then write a report for your insurer evaluating your condition and stating whether you are capable of working.
Despite the name, IME physicians are not truly independent or neutral. Many IME physicians perform hundreds to thousands of examinations for the insurer on an annual basis, meaning they are effectively on the insurer鈥檚 payroll. As a result, they have an incentive to discredit your disability.
However, there are steps you can take to prepare yourself before, during, and after an IME.
Learn more about preparing for an Independent Medical Examination
Knowing why long term disability claims get rejected is just as important as knowing why they get approved. By understanding typical justifications your insurance company uses to deny benefits, you can avoid making common mistakes.
Common reasons insurance companies deny long term disability claims include:
Your insurance company will look for reasons to deny your claim. Don鈥檛 give them an easy one. We always recommend consulting an ERISA attorney to help you navigate the minefield of the disability claims process.
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Experienced disability attorneys understand the claims process. They can gather the correct paperwork, ensure all deadlines are met, and communicate with your insurance company on your behalf.
At Riemer Hess, we create a personalized strategy for every client. Our strategy takes into account all of your needs and concerns. From exiting work to filing your claim, our attorneys are at your side every step of the way to answer questions and provide guidance. Our goal is delivering you a successful outcome with as stress-free a process as possible.
While every client is unique, we do have broader strategies we implement for all our cases.
Learn more about how an attorney can help file your disability
Objective medical evidence
Subjective medical evidence
Vocational evidence
It is essential to incorporate as much supportive evidence you can with your long term disability claim. The more evidence you submit to your insurance company, the better chance your claim will be approved.
Below we will outline how to obtain different kinds of evidence for your long term disability claim.
The most vital aspect of your disability claim is medical evidence that substantiates your restrictions and limitations. Medical evidence can come in many forms, such as office visit notes, testing results, diagnostic films, and opinion letters from your treating doctors. Any objective medical records that show indisputable proof of your disabled condition will hold the most weight with your insurer.
Learn more about how insurers consider medical evidence
The three key types of medical evidence are:
While objective medical evidence will be most important to your insurance company, subjective evidence and medical opinions can still help your disability claim. This is especially true when the subjective evidence and medical opinions are substantiated by objective findings.
Learn more about the three key types of medical evidence
You can help develop a range of medical evidence to support your disability claim. Ways you can help increase your medical evidence includes:
Learn more about medical evidence to prove disability
We often recommend our clients keep a contemporaneous diary of all symptoms. We refer to this as a "Bad Day Diary."
Your diary should include:
Be as specific as possible. Details make your accounting of your symptoms more credible. Documenting numbers (pain scale, length of symptom duration, etc.) also allows a bigger picture to be drawn of how your disability impacts your day-to-day life.
Learn more about keeping a "Bad Day Diary"
If your disability involves cognitive impairment or mental illness, consider a neurological examination.
A neuropsychological evaluation will measure your cognitive deficits in an objective manner. The conducting neuropsychologist will then analyze the results of the testing and provide a detailed evaluation report with their findings. They will also render an opinion on whether your cognitive dysfunction prevents you from performing work duties.
Your medical records may not contain detailed information regarding your cognitive function. A neuropsychological evaluation offers a much more comprehensive assessment of your cognitive abilities. If the findings are supportive of cognitive dysfunction, this will be strong evidence for your disability insurance company to consider.
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A vestibular evaluation is a good option if you suffer from symptoms such as:
These symptoms are difficult to assess objectively. A vestibular evaluation will quantitatively measure the severity of your vestibular symptoms. A vestibular evaluation consists of a series of tests, ranging from Electro/Video-Nystagmography to Auditory Brainstem Response Test to CT/MRI scans. The specific testing involved will depend on your vestibular specialist.
The objective of a vestibular function evaluation is to detect abnormalities in the inner ear. If abnormalities are found, you will have an objective cause for your symptoms. Your insurance company will take your symptoms of dizziness, vertigo, and imbalance more seriously.
Learn more about Vestibular Evaluations and long term disability claims
The tilt table test results can provide strong evidence of conditions that cause dizziness and/or syncope (the medical term for unexplained fainting).
The test is true to its name: It involves the patient lying on a horizontal table that is then tilted upright. During the test, the patient鈥檚 blood pressure and heartrate are monitored by the evaluator. The motion of the table/change of position can trigger symptoms of syncope. The test鈥檚 results can show irregularities in your heartrate and blood pressure that may be responsible for your symptoms.
Many conditions that cause symptoms such as dizziness, vertigo, syncope, chronic fatigue, and lightheadedness can be difficult to prove with objective medical evidence. The tilt table test can be a vital part of your disability claim.
Learn more about how Tilt Table Tests can prove disability
A Functional Capacity Evaluation (鈥淔CE鈥�) should be considered if your disability involves physical limitations.
An FCE gauges your physical function across the spectrum. The assessment is conducted by a trained medical professional, such as an occupational therapist. An FCE involves a series of tests, as well as observations from the specialist conducting the FCE. The evaluation can be done in one day, or across two days. We generally recommend our clients opt for a two-day FCE to obtain a more comprehensive evaluation report.
Some of the physical functions tested in an FCE include:
An FCE report will provide objective data, findings, and test results that underline your physical limitations. This gives your insurance company strong evidence of your work limitations and restrictions.
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It is necessary to show your insurer proof that you are unable to fulfill the duties of your occupation. Beyond medical evidence that proves your restrictions and limitations, you can also obtain vocational evidence that explains what functionality your job role requires. Vocational evidence can be used to give your insurer a clear idea of your occupation and everything it entails.
Learn more about winning long term disability benefits by proving you cannot work
Your disability insurance policy will lay out the definition of disability you must meet to receive benefits. Typically there are three types of occupational standards:
Review your policy carefully to see which occupational standard you must satisfy. This will shape your strategy for filing your disability claim.
Learn more about occupational standards in your disability insurance policy
Your disability insurance company may not have a comprehensive understanding of your occupational duties. A vocational assessment is a great way to provide evidence of what tasks your job role entails.
Vocational assessments are conducted by vocational experts. The vocational expert provides a detailed analysis of your occupation. They will take into account how your disability interferes with your ability to perform your job duties.
Remember, your disability claim relies on:
Your insurance company may accept your evidence of your condition. However, they may argue that your symptoms do not prevent you from working. Offering an expert opinion from a vocational specialist can help counter that argument considerably.
Learn more about vocational assessments
There are two types of limitations to take into consideration for your disability claim.
The insurance company considers these limitations to identify work activities that you can still perform. Identifying all of your limitations will make your claim stronger.
Learn more about exertional and non-exertional limitations
Your insurance company will require ongoing evidence of your disability to continue paying benefits. These update requests can be as frequent as every month. Should you fail to provide sufficient proof of your medical condition, your insurance company may terminate your benefits.
You can take steps to ensure your benefits continue uninterrupted. Below are some of the strategies Riemer Hess uses to protect our clients鈥� benefits.
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If you fail to continue meeting your insurance company鈥檚 standards, they may terminate your benefits. You must demonstrate your condition continues to prevent you from working.
When your insurance company requests updated information, they will look for certain red flags. These include:
You should always be honest with your insurance company in your submitted updates. However, you should also provide any context for alleged medical improvement or inconsistencies with your claim. Your insurance company will never give you the benefit of the doubt. At the end of the day, insurance representatives are searching for reasons to deny paying benefits.
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Your doctor鈥檚 support is essential to your claim鈥檚 ongoing approval. If your medical records do not reflect your continued disability, your insurance company may use that as a basis to terminate benefits.
Here are examples of 鈥渞ed flags鈥� for insurance companies from your doctors:
Doctors are busy individuals. They did not go to medical school to fill out insurance paperwork. You can head off some of these red flags by reviewing all paperwork your doctor completes for your insurance company before submitting it. You can also make sure to communicate every symptom you are experiencing at every appointment. This helps ensure all of your symptoms are recorded in your treatment notes.
Learn more about "red flags" from your doctor that endanger long term disability benefits
Most ERISA long term disability insurance policies require claimants file for Social Security Disability. If you file for SSDI and become approved, your LTD insurance company will deduct that amount from your insurance benefit. This is called an "offset." Your insurance company prefers you be approved for SSDI so they can lower what they pay out of pocket.
Learn more about SSDI and LTD benefits
Long term disability insurance companies regularly spy on their claimants. Your insurance company wants proof you are lying about your inability for work. Should your insurance company surveil you performing activities contradictory to your stated limitations, they may use this as reasoning to terminate your benefits.
Surveillance can come in different forms, including:
It may seem shocking, but long term disability insurance companies pay millions a year for investigators to spy on their claimants. Always be vigilant of your public activities, both in real life and online.
Learn more about surveillance tactics from insurance companies
Long term disability insurance companies routinely monitor their claimants鈥� social media. This includes:
Internet research is an easy way to dig up potentially damaging information on a claimant. Always be aware of what you post publicly on the internet 鈥� and what others post about you. It is all too easy for your insurance company to take an innocent post or picture out of context. If they can use your social media as grounds to terminate benefits, they will.
Learn more about social media monitoring by insurance companies
You may wish to return to work, either in your own occupation or another.
Always consider how your employment will affect your insurance benefits. Your wages must be reported to your insurance company. In turn, your insurance company will reduce your benefit by any earned income. Your insurance company could potentially terminate your disability claim, depending on your new occupation and the terms of your policy.
We always recommend consulting with an attorney if you are receiving disability income and wish to pursue new employment.
Learn more about earned income and LTD benefits
Termination of disability benefits can be devastating. But benefit cancellation isn鈥檛 the end of the road. Options exist to reestablish your benefits.
Typically your course of action to reinstate benefits is filing an appeal through your insurance company鈥檚 internal administrative process. Your denial letter should include instructions on the appeals process. This includes the deadline to file your appeal. In most cases, your policy dictates you must go through your insurance company鈥檚 internal appeals process first. Should you be denied again, you may then file a lawsuit.
If your appeal is approved, you will be paid back benefits to the date of termination.
Check out the section below where we discuss strategies for filing an appeal with your insurance company.
Learn more about dealing with long term disability cancellations
We always recommend you consult with a disability attorney. Experienced ERISA attorneys can help monitor your disability claim and prevent benefit termination.
At Riemer Hess, we regularly assist our clients with fielding requests from their insurance companies. This includes:
We understand what evidence your insurance company seeks to continue paying benefits.
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If your long term disability claim is denied, or your approved claim is later terminated, you have options to reinstate your benefits. Your insurance company will allow you to appeal through their internal administrative process.
You may be tempted to rush your appeal submission with hopes of getting your benefits back quickly. However, that can backfire. Taking the time to prepare and file your appeal with as much substantive evidence as possible gives you a better chance at overturning the claim denial. Keep in mind that if your appeal is denied, your only recourse may be expensive and drawn-out litigation.
Below we鈥檒l answer common questions and discuss strategies for preparing and filing a long term disability insurance appeal.
ERISA provides that your insurance company must allow you a minimum of 180 days to file your appeal. The 180-day countdown starts from the date of your denial letter. If you have an individually purchased insurance plan, check your policy. The deadline may differ.
Meeting this deadline is crucial. Should you submit your appeal late, your insurance company may deny it outright.
Learn more about disability insurance appeal deadlines
There is no one way to win an LTD appeal. However, at Riemer Hess we have developed tried-and-true strategies we use with every client.
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Your insurance company will make a decision on your appeal within 45 days. It is possible your insurance company may ask for an extension to render a decision. This only happens if they send a letter citing special circumstances (for example, waiting for a reviewing doctor's report).
An extension allows your insurance company another 45 days. At most you would have 90 days from submitting your appeal to hearing a decision.
Learn more about the basics of long term disability appeals
Your appeal is your last chance to introduce new evidence to support your disability claim. The specific evidence you should obtain depends on the nature of your disability. However, there are a variety of evidence options available to you.
Learn more about additional evidence for your disability insurance appeal
Getting your appeal right is critical. Your appeal is likely your last option before litigation. Suing your insurance company will be a drawn-out and costly process. You can avoid the expense and frustration by filing a successful appeal.
At Riemer Hess, our attorneys know what it takes to file a successful appeal. Our approach involves obtaining as much evidence as possible to rebut your insurance company鈥檚 reasons for denial. We address all of your insurance company鈥檚 arguments and submit a thorough, comprehensive appeal that proves you are unable to work.
If you fail to submit evidence at the appeal stage, you may not be able to introduce it should litigation become necessary. An experienced disability insurance attorney will understand how best to convince your insurance company to overturn their decision.
Learn more about how our disability lawyers win long term disability appeals
If you鈥檝e thinking of applying for long term disability benefits, need to appeal a denial or termination, or need assistance maintaining ongoing benefits, you should consult with a qualified long term disability attorney. An experienced ERISA long term disability attorney can help increase your chances of claim approval.
Our New York long term disability lawyers can assist you. Call 糖心直播 at (212) 297-0700 or click the button below for a consultation on your disability case.