You were injured on the job – say you fell off a ladder and hit your head and injured your back. You were hospitalized, and spent a long time in rehab. You are better now, but far from all better, and very far from where you were before you fell. In fact, you aren’t able to return to work. Your doctor agrees. When you consult your employer, your employer agrees. This is why long-term disability insurance, which may be provided by your employer, exists, and so you file a claim. It will be a slam-dunk, right? After all, everyone agrees you are too disabled to work.
But you see, it's not up to them.
The disability insurance company determines whether you are entitled to benefits under the policy.
Not only is the insurance company (not your employer) responsible for paying your disability benefits if you can no longer work, it is the one that determines whether your disability meets the specific, legal definition outlined in your policy – or not. You and your employer may have a great relationship, long term and loyal, and your job may think you should get the benefits you deserve (they know you and know you have a legitimate injury and would be working if you could).
But you don't have that kind of relationship with the insurance company. Not only would they like to limit your benefits, it's their job - so they are trained to will look for every possible reason to deny your claim. Remember, they know that a certain percentage of people won't take any other action, just accept the insurance company's decision - so they win a certain number of cases right then and there.
Don’t let that be you! Here are a couple of things to remember as you go into this process:
Always follow your doctor’s recommendations and orders. If you're like most people, even with a serious injury or medical condition, you may feel good enough on any given day to do a little more, to test your doctor's limitations. So on a day you are feeling OK (or just really sick and tired of your physical limitations), don’t help one of your kids move, lifting and carrying stuff if your physician says you shouldn't do any heavy lifting. Yes, it has to get done, but someone else will have to do it. It may be the one day in the last 6 weeks that you feel good enough to try that, but it can hurt your claim for disability benefits. How will the disability insurance company know? Two basic ways. Some insurance companies require you to complete a form called an activity log as part of your claim, where you list what you've done or can do as far as physical activity. Especially if you've applied already, are getting disability benefits or have been denied, they may have their investigators watching you and videotaping you to see if they can catch you doing physical activity that is outside your limitations, even if it's only for a few minutes.
Next, make sure you understand, and are clear on, the role and motivations or limitations of the people who are giving you advice on your long term disability claim. The well meaning corporate person in your job's Human Resources department probably does not understand how to interpret all of the terms, definitions and clauses in your insurance disability policy, and probably doesn't know much about how ERISA disability claims are handled in federal court, or why you have to include all of the evidence in your appeal. If their is a claims person or lawyer from the insurance company, he or she works for the insurance company, not for you – and any outside attorney he or she recommends will probably be biased towards the insurance company, if that is where they get all their clients from. You probably wouldn't recognize a really good private investigator - was he the guy who knocked on your door saying he was concerned about a neighbor you don't like, and you two, just got to talking? Funny how he said he had a similar injury as yours, what a coincidence. Finally, there is just too much misinformation out there - from friends, family and co-workers. They all mean well, but they probably don't really know what can help or hurt your case.
These are important things to keep in mind, especially if you are just starting out in this process, but there is a lot more to do in order to file a successful ERISA long term disability claim. In our other practice areas, we sometimes tell people they can handle their car accident or workers comp injury case on their own, that if the injury is minor, they don't even need a lawyer.
But if you're considering or have filed for long term disability, you probably have a life changing injury or illness and need to protect everything you've worked so hard to get, so you don't lose everything you've worked for. You should at least talk to a lawyer who handles these cases to advise you
And if you received a denial letter under an ERISA policy, you probably have only 180 days to analyze the policy, review and analyze the insurance company's claim file, develop a strategy, get testing or medical evaluations or vocational assessments, formulate the evidence you need and write the appeal.
You probably only get one chance at the appeal - so make it count.
And if you have questions on your ERISA long term disability claim or received a denial letter from the insurance company, call us at (202) 393 - 3320 and let's see if we can help you with your next steps.