Answers to Medical Malpractice, Workers Comp, Long Term Disability Insurance, and Car Accident Questions
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At Donahoe Kearney, we believe it's important to empower through education. Here are some of the questions people have when they first contact us about D.C., Maryland and Virginia medical malpractice, serious car accidents, long term disability insurance claims, or workers compensation. We try to provide as much information as we can based on our experience as medical malpractice lawyers in D.C., Maryland and Virginia.
Since every person is unique, if you have questions or need information about an injury or death in your family, please contact us to talk it through.We'll talk to you, schedule a free initial meeting and give you all the information we can. Call us today at 202-393-3320.
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Did Mutual of Omaha Deny Your Long Term Disability Claim?
Mutual of Omaha Denied Your Long Term Disability Claim in DC
As long term disability lawyers, we know that as a high income earner, you've relied on Mutual of Omaha or another insurance company to provide long term disability benefits while you can't work due to an injury or medical condition. Usually there are two instances when they deny or terminate your long term disability benefits. When they make this decision, Mutual of Omaha or your insurance company will send you a letter informing you.
Here are two common situations involving long term disability benefits being denied, and what to do about it.
Mutual of Omaha denies your initial application for long term disability benefits.
After a serious injury or illness that left you unable to work, you probably applied for long term disability benefits, either through a private policy you purchased and paid the premiums on, or one provided by your company or employer.
If the policy is provided by your company or employer, your HR specialist will usually get you the application and forms you need to get started, and you'll get a packet of information from Mutual of Omaha, (and this is true whether you're applying for long term or short term disability benefits. ,
One of your first steps is to get a copy of your long term disability insurance policy from Mutual of Omaha.
The long term disability benefits policy will include all of the terms, conditions and definitions that apply to the policy, or insurance contract, and information you need to apply for disability benefits. You want to analyze that insurance policy and understand all of the policy provisions.
Mutual of Omaha will usually call you to get information adn probably send you forms for you to fill out, asking for information such as:
- Work History
- Health History
- Job Description
- List of health care providers
- How the injury or medical condition occurred or when you were diagnosed
They will also include an Authorization for the Release of Medical Records. Once you sign this form, it will give the insurance company the right to obtain your medical records and information to verify your medical condition or injury and the fact that you are disabled because of it, and it may allow them to talk to your physicians as well (you want to avoid this if you can).
It's critical to work with your doctors throughout the long term disability process.
Mutual of Omaha, like other disability insurance companies, will have specific definitions of disability, what conditions are covered, and for how long. Its important to analyze the policy and then work to educate your doctors so that they understand the terms and conditions (for our clients, we meet with and talk to physicians, specialists and expert consultants).
If your doctors are like most practicing physicians, they will only take a minute to look at a form or listen to you about this - or they will delegate it to a staff member. Let's face it, most doctors already think they know what it means to be disabled and they often don't give a lot of support for the opinions they put in their medical reports.
The reality is, they don't understand your disability policy definitions and don't have the time to review the policy.
Many doctors want to help, but they end up hurting your claim for long term disability because they use the wrong definition, or include medical conditions that are secondary but may limit your ability to get disability benefits. It's hard work convincing them, even though they mean well.
Here's a common reason Mutual of Omaha and other insurance companies deny a claim for long term disability.
This is another problem with just sending a form to your doctor and expecting he will take care of it for you.
After completing and sending in your application for long term disability benefits, signing everything and requesting the supporting medical evidence from your doctors, you think you're done.
But you're just getting started.
When Mutual of Omaha, or any long term disability insurance company, doesn't receive all of your information, they will write to you asking for more time to gt it (almost all long term disability cases are covered by ERISA, a federal law, that has deadlines and regulations for when claims need to be filed and decided by).
It is your responsibility to get Mutual of Omaha the medical records and other information they request for your long term disability claim - you can't rely on your doctor's office to comply with their request. And even if Mutual of Omaha requests it for you, it's not their responsibility to do this for you.
Naturally, we take care of this for our long term disability clients.
Remember, if you don't get those medical records to Mutual of Omaha on time, they can deny your claim for long term disability benefits. Unfortunately, many people with legitimate medical conditions and injuries that prevent them from working don't realize what they need to do about it, and when.
What to do when Mutual of Omaha denies your claim for long term disability benefits.
ERISA is the federal law that governs most long term disability insurance claims and, in addition to the statute and federal case law decisions, has a set of implementing regulations with requirements both you and the insurance company need to comply with.
First, Mutual of Omaha will send you a letter telling you that your claim for long term disability has been denied. The letter should review the evidence they had, what they reviewed, what actions they took (for example, having your medical records reviewed by a doctor of their choosing). The letter will set out the long term disability insurance policy definitions, terms and conditions that they say apply to your specific situation, where to send your appeal and the date it is due (under ERISA, that is 180 days from the day you receive the letter denying or terminating your benefits).
There have been recent regulations that have extended the filing time limit due to Covid, but an appeal requires significant work, analysis, medical testing, working with medical specialists, preparing witness statements, vocational evidence, legal analysis and drafting, so you want to get started right away.
Get an Experienced Long Term Disability Lawyer to Analyze the Letter Denying Benefits.
If you received a letter denying or terminating your long term disability benefits, our team will review and analyze your denial letter absolutely free of charge, with no obligation whatsoever, and will outline some of the steps you need to take to generate the strongest and most persuasive appeal you can.
Once you have this valuable resource, you can use it as a basis for drafting and filing your own appeal (it's a lot more than just filling out a form). Eventually you may be in federal court (ERISA is federal law) where a federal judge will decide the case based on the appeal you filed and the evidence you submitted to support it.
Fax or Email Us the Letter You Received that Denied or Terminated Your Long Term Disability Benefits
To send us a letter you received from Mutual of Omaha or any other long term disability insurance company, just email it to [email protected] with the subject line: Denial Letter, or fax it to us at (202) 393 - 3324.
Or call us today at (202) 393 -3324 to get our valuable resources and to get started.
The Long Term Disability Claims Rep Says I Have to Show Proof of Disability to Continue Benefits. What Does That Mean?
Proof of Disability in Long Term Disability Claim
After you have been awarded long term disability benefits, most long term disability insurance companies require you to show proof of ongoing disability, and sometimes it is called "proof of loss". Some of that will depend on your specific long term disability policy, but there are some common requirements, such as:
- the long term disability company (Mutual of Omaha, Hartford, Guardian, Reliance, etc) will have internal guidelines for reviewing your claim.
- the insurance company can require you to provide proof of disability at certain points (usually every 45 - 90 days or so)
- the insurance company can require that you are under the care of a physician
- the insurance company can send you to one of their doctors for an evaluation
How Do You Prove Disability in Your Long Term Disability Claim?
The first thing to do is to make sure your doctor understands the physical and mental aspects of your job, so that your doctor can address all of the relevant restrictions and limitations from your medical condition or injury. Its a common misperception, but your doctor doesn't necessarily have to say you are "disabled" or that you can't work at the job.
But the doctor does have to provide the limitations on your functioning (and those limitations or restrictions should lead to the conclusion that you can't do that job). Here's an example of how restrictions and limitations match up with your job duties:
As a bank manager, your duties may include things like supervising employees, verifying cash counts, making decisions, using judgment, interacting with the bank's customers, scheduling deposits. But a severe concussion has impacted your ability to think clearly, to make decisions, to process information quickly, to remember things clearly and to follow directions.
The physician treating you for post concussion syndrome should be able to address whether you are able to make decisions at a pace appropriate for a bank manager, whether you have memory loss, altered or affected judgment.
Usually your long term disability insurance company will have a form for the doctor to complete. And its important that you meet with your doctor to make sure the doctor understands all of your symptoms and problems with functioning. And that should also appear in your doctor's records.
Is Proof of Loss Different than Proof of Disability?
That really depends on your long term disability policy. Some insurance companies use the terms interchangably, or as an initial determination of whether you are disabled according to the policy. So proof of loss may require you to provide:
- Evidence of your income, such as tax returns or W-2s
- Medical information - doctor's reports, diagnostic tests, treatment notes, etc.
- Evidence of Other Income Benefits (social security disability for example)
- Most policies will also require you to apply for Other Income Benefits like social security disability because they can use those to reduce the amount of long term disability benefits thay have to pay.
In addition, the long term disability insurance company can have you examined by a physician or other specialist of their choice (such as a vocational rehabilitation counselor or functional capacity evaluator) or interview you, as part of the Proof of Loss determination.
How Can a Long Term Disability Attorney Help You Prove You are Disabled?
As long term disability attorneys based in Washington, D.C., we talk to people who are struggling with keeping up with the insurance company's endless demands on them and their doctors to continue to prove they are disabled - often a consulation with a long term disabilty attorney can get you on the right track.
And a common way to deny long term disability benefits is for the insurance company to say you do not have sufficient limitations or restrictions, so aren't disabled as defined by the policy.
If your long term disability benefits are denied or terminated by the insurance company, you only have one chance to appeal - getting a long term disability attorney, one experienced with working with physicians and other experts you'll need to prove your claim, is a smart choice.
Call us today at (202) 393 - 3320 with your questions on long term disability benefits in D.C. We're here to help.
My Long Term Disability Benefits Were Denied and I Need to Appeal. Should I Get an Attorney to Appeal?
Get the Right Lawyer to Appeal Your Long Term Disability Denial
Do you need a lawyer for your long-term disability appeal? The answer is almost always yes.
If you have been denied long term disability benefits or your benefits have been terminated, and you have a serious medical condition or injury that prevents you from working, you probably have too much to lose by trying to appeal yourself.
And under ERISA (the federal law that governs most long term disability plans provided as an employee benefit through your job) your appeal is the most critical component. Here's why your appeal is so important:
- The appeal goes to the disability insurance company that just denied or terminated your benefits (that sounds crazy that the same company gets your appeal, but that is the inital step).
- You can add evidence - medical records, opinion letters, reports from experts and specialists, diagnostic test results, etc. that supports the fact that you cannot work due to your illness or injury, and that the insurance company will have to consider.
- You need to argue your case in your appeal, based on the law and the analysis of the insurance company's decision to deny benefits under the policy and their denial letter.
- You can add witness testimonials from people who know your condition, what you are going through, and what your job requires
- You can rebut the evidence the insurance company used to deny or terminate your long term disability benefits - did they have a physician review your records, do they have surveillance video they say shows you can work, do they think your job is physically less demanding than it is, or that you could work in another, similarly defined job?
- Your appeal is part of the administrative record that a federal judge will use to decide your case for long term disability benefits if your case goes to court.
There are certain types of cases that people can handle on their own, especially if they have a minor injury (and we tell people that every day). But this isn't one of them.
If you have a medical condition, illness or injury that is severe enough that you can't work for 6 months, it is probably permanent and may prevent you from working for the rest of your life, even with good medical care and treatment.
That is a lot of income to replace - which is why you have long term disability insurance that you either purchased or were provided by your company as part of your employee benefits and compensaton package.
And most people don't know how complex and difficult long term disability cases are (most lawyers won't even handle these cases). But don't risk everything you've worked hard for on a system that combines law, medicine, regulations, and insurance - get the right lawyer to help you and your family, so you can focus on getting better.
Get The Information and the Help You Need Today
You're making a big decision for yourself and your family, and we are here to provide the information you need to make the right choice. Download our free report Claim Denied: The Ugly Truth About Long Term Disability today at no cost or obligation. After reading this free report you will be 100% more prepared to navigate your future with a long term disabilty claim.
Ready to Speak to An Attorney Today?
We're here to help, so call us today at (202) 393 - 3320 to talk about your long term disability issue. We have a number of options to help you wherever you are in the process, even if you're just applying and have questions or concerns. And if you received a letter from your insurance company denying or ending your long term disability benefits, send that to us at [email protected] and we will review it at no charge, in confidence and with absolutely no obligation. We'll give you options and what we think your next steps should be based on the specifics of that denial letter.
If I Appeal My Long Term Disability Case, Or If It Goes To Court, Will I Have to Testify in Court?
You Probably Won't Have To Testify In Court If Your Long Term Disability Appeal Is Denied.
Most long term disability insurance policies provided by an employer as part of your employee benefits or compensation package, are governed by a federal law, ERISA (Employee Retirement Income Security Act), so if there is any litigation on your claim for long term disability benefits, it will be in federal court.
Here's how it works:
If Your Claim For Long Term Disability Benefits is Denied or Your Ongoing Benefits Are Terminated, You First Have to Appeal That Decision.
Appealing a denial of long term disability benefits is difficult, especially for someone who can no longer work and is dealing with the effects of a serious injury or medical condition (which the disability insurance company doesn't believe or doesn't believe prevents you from working).
Your appeal to the insurance company is the most critical step in the process.
It is much more than completing a form or sending in some medical records from your doctor. You need to analyze your long term disability policy - the definitions, terms and conditions, exclusions and limitations, etc. - will help you get started on what you need to prove.
You need to analyze the denial letter and request a complete copy of your claim file from the insurance company (which may be hundreds and hundreds of pages - make sure you specifically ask for everything).
If your long term disability insurance policy is an ERISA policy, there are regulations that govern how the insurance company evaluates and decides your appeal. As you know, the insurance policy is written by the insurance company - not only does the policy favor the insurance company, federal courts have routinely ruled in favor of disability insurance companies based on a number of factors set forth in the policy, including the standard of review the Court uses.
If Your Appeal To The Insurance Company Is Denied, You Can Sue The Insurance Company In Federal Court.
Once your appeal is denied, you can file a lawsuit to get the long term disability benefits you are owed. But there is a critical difference between an ERISA disability lawsuit and a case involving any other serious injury or medical condition - a medical malpractice case or trucking accident case, for example.
Under ERISA, the federal judge who decides your case will decide it based upon the administrative record - that is, everything your long term disability insurance company had when it denied your appeal. There won't be any discovery, depostions or additional evidence. You won't have a jury trial.
That record will include everything you submitted as part of your appeal - so you have to make it count. That's why we focus on the appeal, on generating all of the medical, vocational and other evidence necessary to prove that you are disabled as defined by your specific policy. While this would not include testifying in court, we interview you (and others with knowledge of your medical condition and job) extensively to prepare a powerful statement as part of our evidence.
Unfortunately, we've turned away people with legitimate, serious medical conditions who are ready to file their case in court because they did not properly and thoroughly file an appeal - and there won't be enough evidence, or the right kind of evidence - for the judge to rule in their favor.
If Your Long Term Disability Insurance Policy Is Not Governed By ERISA, You May Be Able To Testify in Court.
Again, most policies fall under ERISA but some are private, state law contracts. If you have an disability insurance policy that isn't covered by ERISA, you may be able to sue the insurance company in state court, like almost any other case and have discovery, including your deposition. And if the case goes to trial you may testify in court.
Download Our Free Report To Get The Information You Need Now
If you're just getting started in the process, you need the right kind of information to make good choices for yourself and your family. We have a free report you can download and read to better understand what will happen if your claim is denied and the dangers of handling the claim on your own. Download this free report now.
Talk To A Long Term Disability Attorney in DC
If your long term disability benefits have been denied or terminated, fax us your denial letter from the insurance company. We'll review it for free, in confidence, and with absolutely no obligation. Just send it to [email protected] We'll give you or thoughts on what you should do next.
And we offer different levels of service depending on your needs - maybe you are just applying for long term disability and only need to consult with us for an hour or two, or you've been denied and need to research, draft, prepare and file an appeal.
We're happy to help. Call us today at (202) 393 - 3320 to get started.
How do the smartest executives working in DC get long term disability benefits when they can't work?
Getting Long Term Disability Benefits After A Serious Illness or Injury.
If you're like most executives working in DC you've worked really hard for your entire career to make a difference and provide for your family.
You had absolutely nothing given to to you. You paid your own way. You earned it.
But what happens when a medical condition or serious injury keeps you from working and you suddenly need long term disability benefits?
First, you have to realize that, even though you may have paid premiums for a long term disability policy for many years, the policy gives your disability insurance company a lot of discretion in how to decide your claim for benefits - it's obviously written to favor the insurance company.
So you don't want to take any chances. Don't give the insurance company the opportunity to deny or terminate your long term disability benefits because you don't know any better.
You don't want to get taken advantage of. You don't want to lose everything you've worked hard for.
How Do I Appeal a Denied Long Term Disability Claim?
If your claim for long term disability was denied, you need to formulate evidence and write your appeal as if a federal judge was deciding your case based on the appeal and the evidence you submit.
Once your benefits are denied under a long term disability plan covered by ERISA (the vast majority of long term disability policies are governed by ERISA) you only have 180 days to file your appeal with the insurance company. This is not just some form you complete - it's an opportunity to add evidence in support of your claim, so you need to work with medical experts, specialists, vocational experts, medical researchers and others to make sure you have the medical evidence (testing, physician reports, expert opinions, medical literature, etc.), vocational and occupational evidence you need.
This is critical because if your appeal is denied by your insurance company (that's who the appeal goes to), the next step is to file your case in federal court (in D.C., the U.S. District Court for the District of Columbia) where a federal judge will decide your case without witnesses or discovery - the decision in your case will be based on the administrative record, including your appeal and everything submitted with it.
In our complex medical malpractice cases, we always say the best way to get a good settlement is to prepare for trial, so we do an incredible amount of work before the case is ever filed in court. The same concept applies here - everything you do should be done to persuade a federal judge and to build your case at the appeal stage.
If a lawyer tells you to wait until you file the case in court, so the other side doesn't know what is coming, or to wait and take the depositions of your doctors, or that you have an aooprtunity to develop your case during discovery - then that lawyer doesn't know ERISA disability cases.
It's Best To Get a Long Term Disability Attorney Working For You Early in the Process
The best way to win a long term disability appeal is to identify all of the additional evidence that supports your disability, analyze the policy, work with your physicians and other specialists and experts to develop additional support that you are disabled under the policy, draft personal statements from you, co-workers and others who have witnessed the effects of your medical condition, analyze the legal weaknesses in the insurance company's decision to deny your benefits, and draft an appeal that incorporates all of the facts, law and medicine.
No matter how successful you are, once you have a serious injury or medical condition, this is an almost impossible task.
Let Our Experienced Long Term Disability Attorney Take This On For You
We start by analyzing the insurance company's position in denying or terminating your long term disability benefits and give you the next steps that can help. And we work with you, your family, your doctors as well as other experts and specialists to put your appeal in the best position to get you the long term disability benefits you deserve.
Call us today at (202) 393 - 3320 to get started.
What do I need to do to get ready to file for Long Term Disability?
What To Do Before Filing for Long Term Disability
First and foremost, get a complete copy of your medical records from your physicians. Some doctor's offices will give you only the physician notes or reports, some will charge you or have some copy service charge you for this, some staff members don't want to deal with it. But whatever the situation, be assertive in getting everything in your medical chart - office notes, labs, orders, prescriptions, referrals, etc. You need to see these before the disability insurance company does, and you have to know what your doctors are saying about your condition or injury and your ability to work before you file for long term disability benefits.
You're injury or condition is legitimate - you're not trying to hide anything. But remember, the insurance company is going to do everything they can to deny or stop your disability benefits, construe everything that isn't 100% clear in their favor.
Here's just a few reasons why you need to review your medical records first:
- There is a mistake in the records (this happens frequently, and with electronic medical records and auto fill on the computer, the mistake gets automatically repeated in every office visit). Examples could be what your job is, how long you've had the injury or condition, what caused it, what your limitations really are.
- Your doctor may not know what "disability" really means under your long term disability insurance policy - in other words as it is defined in your specific policy - not the common, dictionary or medical definition.
- The records aren't complete - there are visits, labs, tests, etc. that are not in your medical chart.
- Your doctor isn't a specialist or doesn't have specific expertise with your specific injury or condition and some of his notes could be misinterpreted by the insurance company. It's not that he doesn't understand your condition and that you can't work, but that his notes are vague, general or not very specific.
Medical Providers and Insurance Companies Have Completely Separate Agendas
Keep in mind that none of this really matters as far as your medical treatment goes - and that is what your doctor is focused on. Many doctors are squeezed by health insurance reimbursements and view documentation as one more thing they have to do - but it's critical for your long term disability claim. Obviously, you want a copy of your records so you can identify if you have any of these issues before you file your claim, and so you can take steps to correct them by talking to the doctor, getting a follow up exam, a second opinion, etc.
In every case, the disability insurance company will review these records closely, looking for everything they can (any mistakes, inconsistencies, omissions, etc.) they can use to deny benefits. The insurance company will have their own medical consultants and experts review your records - and you can bet they are trained to look for every inconsistency, mistake, anything that is vague or doesn't specifically describe your injury, condition and inability to work. Your medical condition and inability to work is real and legitimate, so make sure your medical records are good enough to satisfy the insurance company under the policy and qualify for benefits.
You Stand to Lose a Lot if You're Not Careful About Managing Your Medical Records
If you don't review your medical records and just send them to the insurance company, you may set yourself up for a denial of your claim - that's what your long term disability insurance company is hoping for. If you want more information on how to prepare for your ERISA long term disability claim, or want to talk it through, just call us at (202) 393 - 3320.
How do I request my claim file after I've been denied long term disability?
After you receive a denial letter from your long term disability insurance company, one of the first things you should do is request a complete copy of your claim file.
Why you should request your claim file after your long term disability benefits were denied.
The claim file should contain all of the information the insurance company used to deny your claim for long term disability benefits - many times the claim file will be several hundred or more pages long. And it's a critical piece in the evaluation of your appeal - and remember, filing a well written, thorough appeal with additional medical records, reports from specialists and experts, research, medical literature, vocational information and persuasive evidence is absolutely critical. It will be used by the insurance company to decide your appeal, and then by a federal judge if your case is filed in court.
An appeal of the denial of long term disability benefits is not just filling out a form or writing a letter!
Since you only have 180 days to file an appeal, you should request the claim file as soon as you can, and the insurance company can not charge you for this, it is free of charge.
Under ERISA, the insurance company has 30 days after your request to send the claim file to you.
How should you request your long term disability claim file?
First, carefully review and analyze the letter denying benefits that you received from the disability insurance company as to why they say you are not entitled to benefits for your injury or medical condition. Many of these will have an address you can write to with your request, but call the person who signed the letter for the insurance company - you may be able to email or upload your request instead of mailing it.
As long term disability lawyers in Washington, D.C., we draft a specific request for the claim information that requests 15 - 20 types of documents and materials, and we do this as soon as someone hires us to review their denial of long term benefits. We know the clock is ticking and we want to get to work on your appeal!
Get help with your long term disability claim in DC
As long term disability benefits lawyers in DC, we offer a range of services to help with your long term disability claim. If you've been denied long term disability benefits, call us today at (202) 393 - 3320 for a free, no obligation, confidential review of your denial letter so we can analyze your specific situation.
If you're thinking you should apply for long term disability but haven't yet, we offer consultations (now by video) to review your situation and provide a strategy to help you through the application process as well.
How Can I Get From Short-Term Disability To Long-Term Disability Smoothly?
Going From Short Term Disability to Long Term Disability
Most people don't realize that short term and long term disability are totally different - different policies, administration, time limits, types of injuries and medical conditions, just to name a few. So even if both types of policies are provided by your employer, you may have very different benefits and claims policies available.
A lot of short term disability policies cover you if you can't work for anywhere from a few months to 2 years. They typically have a short waiting period, about 14 days, and require a less intensive application policy and review. Many times, these applications are granted quickly. They may have exclusions - for example, they may exclude injuries that happen at work.
So does getting approved for short term disability mean you will be automatically approved for long term disability? You would think that but it's not the case. Many times the short term disability is really the employer's money rather than the insurance company's money - the disability insurance company just administers the policy.
And you can be denied for short term disability and still get long term disability benefits.
Long term disability can cover you for many years if an injury or medical condition prevents you from working in your occupation, or after a period of time, any occupation, and typically these policies cover you until age 65. Like short term disability, there are usually exclusions, often for mental illness, for example, and the application and review process is more rigorous. These policies often require you to apply for social security disability (and take a credit if you're approved and getting social security disability).
Keep in mind - all long term disability insurance policies are written to favor the disability company, and the federal law that governs disability claims (ERISA) is much more favorable for disability insurance companies than it is for employees with legitimate, serious injuries or medical conditions that prevent them from working.
And the key is - if you've received a letter from the disability insurance company denying or terminating your claim for benefits, call us so we can arrange to review the denial letter (in confidence and free of charge) and give you our analysis of what to do to put your appeal in the best light. But under ERISA, you only have 180 days and that's not a lot of time for the amount of work involved.
Call us today at (202) 393 - 3320 to get started.
My long term disability claim from my job working in D.C. was denied. Where do I file my long term disability appeal?
If your long term disability benefits were denied, you have the right to appeal.
If you were working for a private employer in Washington, D.C. and applied for long term disability benefits under a long term disability insurance policy, you have the right to appeal that decision.
If long term disability benefits were provided as an employee benefit from your company, the disability plan will be covered by a federal law, the Employee Retirement Income Security Act (ERISA) and there are certain rights and responsibilities ERISA gives claimants (claimant is the term for the person who is disabled and is making a claim for long term disability).
Your first appeal is to the insurance company that just denied your long term disability claim.
There are several basic rights under ERISA. First, you should request a complete copy of the claims file - everything that the insurance company considered in it's decision to deny your claim for benefits.
Second - you only have 180 days from the date you received the letter denying your benefits to appeal your case.
So request that claim file (or have an experienced DC long term disability attorney request it for you) immediately so you can begin to analyze the insurance company decision and the legal and medical basis for that decision denying your benefits.
An appeal after a denial of long term disability benefits is a lot more than filling out a form.
Many people make a critical mistake that can't be fixed later.
Instead of approaching the appeal and denial of benefits like an experienced long term disability lawyer, they just fill out a simple form or write a letter indicating they don't agree with the decision - just like the denial letter says they have a right to do!
Sometimes they will send in a few more recent medical records about their disabling condition.
But they won't schedule additional medical testing, or a Functional Capacity Examination, or a vocational rehabilitation specialist evaluation. They won't interview co-workers, conduct medical literature searches, perform opposition research on the physician who reviewed their medical records, review specific policy provisions with their doctor to generate highly specific, individual reports from the doctor.
There are 2 basic reasons why someone who is disabled should not file their own appeal.
- There is no way to understand ERISA law and procedure unless you have been in this field - you didn't ask for this and have never been through this before - how could you know whether you are making a mistake that ends your disability benefits forever?
- You have a disabling medical condition or injury that you need to focus on. You don't have the stamina, endurance or time to take on this kind of legal work.
Take it from an experienced long term disability attorney - you only get one shot at your appeal.
That's because if your appeal is denied by the insurance company, your next step is to file a lawsuit against them in federal court (since ERISA is a federal law).
So your case will be decided by a federal judge - there is no right to a jury trial under ERISA. And the judge will consider the administrative record of your appeal - all of the information, evidence and medical records you used to support the appeal will be part of that administrative record.
What do you think your chances of winning are if all you did was fill out a form or send in some medical records?
Call our experienced long term disability lawyers today at (202) 393 - 3320 to discuss your long term disability claim in DC. We offer a number of cost effective ways to help you get the disability benefits you and your family deserve.
Can I work if I'm getting long term disability benefits?
Work and Long Term Disability Benefits
We fight insurance companies on behalf of people every day. If you were denied long term disability benefits for your injury or medical condition, you know how difficult that process is. Many long term disability insurance companies deny tons of people because they know that some people won't appeal at all.
It's an unfair strategy, but it works.
So once you are back getting benefits, is it OK to work?
Probably not. Here's why:
Insurance companies will use any activity related to work, including volunteer work (for people who work with us, we have an entire interview and assessment process that analyzes and explains this for your specific situation) as a basis to deny or terminate your long term disability benefits - many times before you are fully recovered or ready to return to work full time.
What if you're receiving long term disability benefits and want to return to work?
First, you'll need to thoroughly review your long term disability insurance policy.
Most long term disability policies have 2 terms and conditions you should be familiar with: "own occupation" and "any occupation." During the "own occupation" time period, you qualify for benefits if you cannot perform the primary duties of your own job. But after a period of time (your specific policy will indicate this) you qualify for benefits only if you can't work in "any occupation."
There are a few other terms and conditions in your long term disability policy to identify and analyze:
- How Total Disability and Partial Disability are defined
- Offsets for "other income" which allow the insurance company to reduce your benefits
- Vocational rehabilitation programs and incentives to work
Working with your doctor is critical to your long term disability claim.
You need to constantly educate your doctors on this process - they are busy and don't have the time or expertise to analyze the specific terms, definitions, conditions and law that apply to your long term disability benefits.
If you think you can return to some type of work, discuss it with your doctor and have him examine you first.
- Have your doctor thoroughly document any physical restrictions or limitations
- If your doctor agrees you can try to return to work, have the doctor write a detailed report that documents the exam findings, restrictions and limitations you have and indicate that you are approved to attempt to try to return to work for a trial period. If the trial period works, that is great, otherwise you can use it as evidence that you cannot work.
Be honest with the long term disability insurance company.
It's important to provide the insurance company with the medical records that document you can return to work for a trial period and disclose any income you receive.
And be upfront with your employer about your physical limitations and restrictions as well.
We hope these tips help with a healthy, long term transition back to work - one that puts you in control.
Questions about your long term disability plan?
Before taking action, call to schedule a flat fee strategy session with us. We'll review and analyze your policy and medical records and explain how the different terms, conditions and clauses impact your eligibility for benefits, and help you with a game plan so you can make the best decisions for you and your family.
Call us today at (202) 393 - 3320 to get started.