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The Dangers of Waiting to File Your Long Term Disability Claim

| Frank R. Kearney |

Don’t Wait to File Your Long-Term Disability Claim

Whether you are insured with Guardian Life, MassMutual, Assurity, Aflac, or someone else, you want to be careful on how long you wait to file your claim. Here’s a long-term disability case in Washington, D.C. that shows just one of the problems with waiting to file with your disability insurance company.

Remember, if your policy is governed by ERISA, your case must be filed in federal court (this was in the federal court in D.C.) and will likely be decided by a federal judge, often on the administrative record (everything you put into your appeal – which is why your appeal is absolutely critical and you should consult with a lawyer specializing in ERISA long term disability claims).

The case is Hunter v. Massachusetts Mutual Life Insurance Co. and here are a few of the important points for long-term disability claims:

John Hunter was a dentist in Washington DC who had been practicing since 1985. A few years later he bought a long-term disability policy with Mass Mutual. That policy required Dr. Hunter to notify Mass Mutual of an incident within 90 days of the incident occurring so that the company could determine whether to accept or deny the claim and if accepted, determine the benefit rate. But the policy also stated that notice should be provided “as soon as it is reasonably possible.”

Many years went by (over a decade) and Mr. Hunter never needed to act on his policy – he didn’t have any injuries or medical conditions that caused him to be disabled. Eventually, in 2004, Dr. Hunter was involved in a serious crash while riding his motorcycle. In 2011, he filed a claim with Mass Mutual citing the motorcycle accident. When Mass Mutual asked for an explanation as to why the claim was filed outside the 90-day period, one of Dr. Hunter’s physicians said that due to the conditions caused by the accident, he was unable to pursue or understand the option of pursuing his disability claim.

While the claim certainly fell outside of the 90-day window, Mass Mutual accepted the claim and started to pay benefits. In awarding Dr. Hunter his long-term disability benefits, the company included a letter stating that the claim fell outside of the necessary window for it to be qualified.

Dr. Hunter argued that because the accident happened in 2004, he should be entitled to back-dated benefits between the date of the accident and the time that When Should You File for Long Term Disability Benefits filed the claim in 2011. Naturally, Mass Mutual denied this request, citing that too much time had elapsed between the accident and the time the claim was filed to determine the severity of the injury, the extent of the disability, and the number of benefits he was entitled to during that time.

As one could imagine, there was plenty of back and forth in the litigation. John Hunter would argue that because Mass Mutual chose to waive its rights in accepting a claim outside of the 90-day window, he was entitled to backdated benefits. In other words, he argued that because the insurance company chose to accept his claim, they need to accept it to its fullest extent. Mass Mutual argued that even though it accepted his claim outside of their 90-day window, it does not mean they have to fault other parts of the agreed-upon policy in addition to the 90-day notice of claim.

The court ruled in favor of Mass Mutual, citing that while Mass Mutual has the discretion accept a case based on certain criteria that may fall outside of this contractual agreement (such as mandating a notice of claim within the stated 90-day window), the fact that the company accepts one criterion outside of the agreement’s expectations does not entitle the claimant to receive other benefits that lie outside other areas of the policy, including backdated benefits between 2004 and 2011.

Two Important Points if You’re Filing for Long-Term Disability in DC

  1. Read the disability policy, the language in it will control your claim for benefits; and
  2. Don’t Delay. You can’t rely on the insurance company to agree that notice was reasonable or couldn’t have been given earlier, and you may be giving up back benefits or a higher rate of benefits.

If you’ve received a denial of your long-term disability claim, send it to us by fax at 202-393-3324 or email at clientexperience@dkllp.com and we will review it for absolutely no cost or obligation, and set you up with some clear guidance.

Suing the Insurance Company for Your Long Term Disability Benefits in DC.

If you’re like most people, you thought long-term disability was there to help you in case you got sick or injured and couldn’t work. Most people think it is a simple process of filling out some forms and sending the insurance company your doctor’s notes that say you can’t work. And let’s face it, there are a lot of myths and misconceptions about long-term disability claims.

If you’re suffering from a serious injury or illness that prevents you from working, that’s just the start of the process. Before you can sue the long-term disability company that denied or terminated your benefits, there’s a lot of work to do.

How Do Long-Term Disability Claims Work in DC?

We’ve written a lot about how to get started with your long-term disability claim in DC – and it always starts with getting a copy of your specific disability policy to determine the terms and conditions. And if you need to file a claim, make sure you comply with the policy provisions on notice.

You may be surprised at what’s in there, especially if you have a policy that your employer-provided as part of your employee benefits. Most of these policies are written to give the insurance company every opportunity to deny or limit your claim, even with a serious, legitimate injury or illness.

And that’s perfectly legal – courts have allowed insurance companies to do this, and typically interpreted the federal law that governs long-term disability claims, ERISA (Employee Retirement Income Security Act) in favor of insurance companies rather than claimants.

What Do You Need to Know About the Long-Term Disability Process?

Once you receive a denial letter from Mass Mutual or any long-term disability insurance company, you have a lot of work to do, but you can’t sue them yet. Instead, you have to file an appeal of denial with the same insurance company that just denied your claim. And you only have 180 days to do it. The appeal you file in response to the denial letter is a critical step in the process.

You see, if the insurance company denies your appeal, that appeal – all of the evidence you put into it – will become the administrative record that the federal district judge will use to decide your case. Unfortunately, a lot of people and lawyers who don’t understand ERISA disability cases, think that they will get a fresh start after filing a case in federal court (ERISA is a federal law, so these are federal cases). They think they can start the case from scratch and conduct discovery, take depositions, and have expert witnesses, doctors, vocational rehabilitation counselors, physical therapists, supervisors, and co-workers testify about the extent of your illness or injuries and why they prevent you from working.

Most people think that but it’s not true – ERISA disability cases are not like other serious injury cases caused by medical malpractice, or car or truck accidents.

There is no jury trial or discovery. Usually, the federal judge will be deciding whether the disability insurance company’s decision to end or deny your benefits was “reasonable” – and to do that, the only thing the judge will review is the administrative record (your appeal) and the briefs you and the insurance company file.

It’s Not a Fair System – So Know That Going In.

Make sure your appeal is packed with evidence to show that the insurance company’s denial was not reasonable and that they ignored important evidence or misinterpreted something. An appeal will have arguments about why the decision was unreasonable, but to be effective, you must show why your appeal should be granted – and you should be writing it with a federal judge in mind as the ultimate audience.

As soon as you get the letter denying or terminating your benefits, order a complete copy of your claim file, or a good lawyer will do this for you immediately. Depending on your condition and whether you’ve been receiving benefits, the insurance company claim file can be hundreds and hundreds of pages long.

You need to read, understand and analyze all of the information in that claim file – medical, vocational, educational, policy terms and definitions, surveillance (insurance companies routinely spy on you to see if you are working or doing things that are inconsistent with your medical condition or restrictions.

And Keep in Mind – You Only Have 180 Days to File Your Appeal.

The disability insurance company has 45 days to decide your appeal (although this can be extended by an additional 45 days).

What if the Insurance Company Denies Your Appeal for Long Term Disability Benefits?

Even if you’ve put everything you had into the appeal – you interviewed your doctors and transcribed their opinions, you had a Functional Capacity Exam performed to objectively show your limitations, you engaged a vocational expert who indicated there were no other jobs available in light of your physical limitations and training, education, experience, you reached out to expert consultants on your specific illness or injury and provided medical reports, peer-reviewed literature, and other evidence, the insurance company can still say it’s original denial was “reasonable.”

Once your appeal has been denied, you can sue the disability insurance company by filing a Complaint in US District Court (federal court). You can’t do that until you have been through the appeal process with the insurance company (sometimes that’s called exhausting your remedies).

ERISA long-term disability claims are complex and challenging – with tight deadlines, difficult legal standards, and a sophisticated insurance company as an opponent. There are steps you can take to prepare your own case or appeal, but without an ERISA disability lawyer to help, you are at a serious disadvantage.

If you’ve been denied benefits, are having trouble with your appeal, or are thinking about applying for long-term disability benefits, call us today at 202-393-3320 to see how we can help.

by Frank R. Kearney, Attorney-at-Law

Experienced DC Workers’ Comp, Long Term Disability & Accident Lawyer,

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