D.C. Maryland and Virginia medical malpractice, accidents and work injuries questions answered by D.C. injury attorneys.
Here are some of the questions people have when they first contact us about D.C., Maryland and Virginia medical malpractice, serious car accidents 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 and based on representing many hundreds of people who have been injured in accidents or at work in D.C., Maryland and Virginia.
Here are the basics:
Patients permanently injured by medical malpractice, or the families of patients killed because of medical negligence, when a hospital, HMO or healthcare corporation doesn't follow basic patient safety rules deserve justice - resources to help with the harms and losses due to the injuries or death of their loved one.
Drivers who don't follow the rules of the road, driving recklessly, driving drunk, speeding, and texting should be accountable for the harm they cause when their actions cause a car accident or wreck.
Workers hurt on the job deserve workers compensation benefits for lost wages, medical treatment and permanent injuries. If a worker is killed on the job, his family deserves workers compensation death benefits - to at least help with the financial loss of a loved one.
But 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.
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What is Essential Duty Under Your Long Term Disability Policy?
Make sure the insurance company is using the right definition of disability.
You'd be surprised, but this comes up a lot. When you bought your insurance long term disability policy, or when your company did and provided coverage to you as an employee, they were basically paying for a specific definition of disability. The term “disability,” or “disabled,” is specifically, and carefully, defined in your insurance policy (by the insurance company). So how it is defined is critically important - and governs just about every aspect of your claim.
Sometimes the insurance company will terminate or deny benefits after reviewing the claim using a different definition of disability
There is a typical clause, sometimes called the "essential duty" cause that defines "Disability" like this: You are prevented from performing one or more of the Essential Duties of: 1) Your Occupation during the Elimination Period…”
In an ERISA long term disability claim, that work, that means you are disabled (and should get benefits) if you can prove you can't perform one of your "essential duties" due to injury or illness, sometimes this is also tied to the amount of time you can work, so an “essential duty” may include the ability to work full time, or 40 hours per week.
If you received a denial letter from the insurance company, you have to review it carefully (or have us review it for you). One of the first things to look for is the proper definition of disability. So, in this example, if the disability insurance company denial letter indicated your long term disability benefits were being denied because you need to prove "you must be unable to perform the duties of your occupation” you might not even notice the different definition they used to deny benefits.
Here's is why using the wrong, even slightly different definition changed the case. Under that definition, you have to be unable to do each and every job duty to get benefits. Under the terms of your insurance policy, however, you would be entitled to benefits if your injury or illness prevented you from doing just one job duty. As you can see, using the wrong definition allows the insurance company to say you aren't disabled.
Too many people with legitimate injuries and illnesses fall for this trick. You absolutely have to read your insurance policy or contract and make sure the denial letter terminating your benefits cites the correct terms, conditions and definitions in your policy. Above all else, don’t take the insurance company's word for it.
Whether the insurance company makes an honest mistake, doesn't know, or is deliberately trying to screw you, it doesn't matter - the result (a denial of benefits you deserve when you can't work) is the same.
So if you’ve received a denial letter, call us at (202) 393 - 3320 and let us help.
Can I Apply for Long-Term Disability Benefits Even Though My Short Term Disability was Denied?
There is a difference between long term and short term disability.
Let's face it, nearly every aspect of ERISA Disability claims is geared to favor the disability insurance companies and difficult or confusing for the person with the serious injury or illness who is making the claim. Even many judges, lawyers and insurance people find this area of the law confusing. We try to cut through the confusion and help you understand the process of your disability claim and the law and what to expect.
When someone has an injury or illness and can't work, they often apply for Short-Term Disability. If they are denied these benefits, many people assume they can’t file for Long-Term Disability, or that the insurance company has denied that too. It seems to make sense, but that's not right. Here's why:
Why Long-Term Disability Claims Are Really Denied
Your disability claim is governed by the language of your specific disability policy, not whether you can work, or your diagnosis or injury, or whether you are disabled. That's why if two people with the same job, injury or illness, and medical history who have different Long-Term Disability policies, one can be approved for benefits and the other denied.
There are no guarantees when it comes to ERISA long term disability. All insurance companies operate for profit, and if there is a way they can deny your claim, and avoid paying you disability benefits, they will do it.
Your Short-Term Disability policy is no different in this regard. Your claim is approved or denied based on the language in the insurance policy.
You Can Be Denied Short-Term Disability But Still Approved for Long-Term Disability
Your Short-Term Disability policy is a different policy than your Long-Term Disability policy. Sometimes, they are two separate policies written by the same insurance company, so it can be confusing, but remember, it's the policy language that controls.
So if your Short-Term Disability Benefits Have Been Denied, can you file for Long Term Disability benefits?
Yes - a denial of short term disability benefits doesn't prevent you from applying for long term disability benefits.
Since they are two separate insurance policies, they each have their own definitions, requirements and rules. Unless the terms of your Long-Term Disability policy specifically prevent you you from filing a claim based on the determination of your claim for Short-Term Disability, you can file for Long-Term Disability benefits. But make sure to analyze the policy language an terms for the meaning of the “elimination period.” You will probably need to prove you were continuously disabled during the elimination period in order to be eligible for Long Term Disability benefits , but that applies whether you were receiving short term disability benefits or not.
Plus, being approved for Long-Term Disability benefits may help your Short-Term Disability appeal. When appealing the decision of your Short-Term Disability benefits, your attorney can show that you have already been approved for Long-Term Disability benefits and use that to support your Short-Term Disability claim.
What if both Your Short Term and Long Term Disability Benefits Claims Were Denied?
If you have a serious illness or injury and can't work, and your doctor indicates you can't return to work, but your claims for both short term and long term disability have been denied, you should contact a lawyer handling ERISA disability claims to determine how best to appeal, why you were denied and the evidence you will need to try to convince the insurance company that you are disabled under the policy.
Disabilty benefits law is complicated, especially when you're dealing with the effects of a serious injury or illness. So call us at (202) 393 - 3320 with your questions and we can help you take the next step.
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.
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.
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.
Can I get Some Info on Making a Claim Under My Long Term Disability Policy?
Long Term Disability Insurance Denials
There are a number of reasons the disability insurance company can deny your legitimate claim for benefits, even if you can't work because of an injury or medical condition. Unfortunately, most people don't recognize how important the appeal is, or, usually because they are so seriously injured or ill that it will be easy to convince the insurance company that they made a mistake, or they don't know how to respond (how would they, having never been in this situation before?)
Here's some common misconceptions about ERISA long term disability:
All it takes is reading the forms, telling the insurance company about your injury or illness and sending in a doctor's note.
If you just complete the 2 page form from the insurance company, you will get your benefits.
If you have been awarded Social Security disability benefits your long term disability benefits will automatically be approved by the insurance company.
If your doctor writes a note to the insurance company or your medical records indicate you are disabled you will be awarded disability benefits.
If your company or boss tells the insurance company that you can't work because of your illness or injury, you will be awarded benefits.
Here are some of the realities of ERISA long term disability:
Insurance companies are for profit corporations, with a duty to maximize profits for shareholders. One of the ways they do this is by denying claims like yours (and let's face it, they know a certain percentage of cases will go no further, and some people will just accept their denial).
The forms insurance companies send you are really to help them deny claims. By having you answer questions about things you can do that have no relationship to your work, injury or illness, they can say you're not disabled (or don't fit the policy definition).
If you're awarded Social Security disability, your insurance company can still argue that they do not need to follow that determination, even though it is a federal program and the standards for awarding social security disability are higher than most long term disability policies.
There is nothing that requires the insurance company to follow your doctor’s opinions and recommendations (even though that doctor knows your condition and limitations, has probably treated you over months or years and is in the best position to address this). Instead, they will probably hire an insurance medical examiner review your records, and somehow say you can work.
Just like with your physician, the insurance company is not required to follow your company's recommendation. Instead, they will ignore or minimize evidence from co-workers, bosses and people who are in the best position to observe your limitations, and especially the before and after picture.
What Can Do To Combat the Disability Insurance Company?
Here are some general tips to keep in mind as you go through the process:
Get prepared and organized. If you have a condition that is getting worse, get everything in order before you can't work and before you submit a claim.
Do not tell a lie in any part of the claims process. But with any forms you complete, send in all of your supporting documents as well - the forms themselves just aren't enough.
Get an independent lawyer to help with social security when you file for social security disability - the disability insurance company may offer a big national firm to do this for you - but whose interests do you think that firm and lawyer have at heart?
They don't teach ERISA disability claims in medical school. Your doctor may be an awesome physician but doesn't know what will help or hurt your specific disability benefit claim - above all, make sure he or she (or any physician you see) uses the definition of disability contained in the insurance policy. Sometimes the doctor may have a definition of disability in his or her own mind or practice that is different.
Get letters from bosses, co-workers, friends and families who can accurately describe your condition and how it prevents you from working (especially the before and after picture) and include them in your appeal, even though the insurance company may ignore or discount these. If nothing else, if you're appeal is denied and you have to file a lawsuit in federal court, you can argue their denial was unreasonable because they didn't consider this evidence.
And if your long term disability claim was denied, call us at (202) 393 - 3320 for help. We'll review the denial letter for free and tell you what we think. Just remember, under ERISA, you only have 180 days to file your appeal, so don't wait!