You’re in a vulnerable position when you cannot earn a living. We know you’re worried about your finances and wondering how to afford medical treatment. Our long-term disability lawyers will protect your rights and use our knowledge of the state laws to ensure you receive the maximum payments you need.
When recovering from a disability, you have options for supplementing your lost income. Various disability programs allow injured workers to recover a percentage of their average wages so they don’t face financial hardships. If the situation develops into a permanent disability, benefits could last for life.
To learn more about how we can help with your long-term disability claim or appeal a denied claim, call Fusco, Brandenstein & Rada, P.C. at 516-496-0400 to speak with one of our long-term disability lawyers in New York.
What is the difference between workers’ compensation and long-term disability?
Many misunderstand the differences between long-term disability (LTD) benefits and workers’ compensation coverage. People sometimes use the terms interchangeably, but these are different insurance plans. Workers’ comp provides multiple benefits for anyone with work-related injuries or illnesses. At the same time, long-term disability may replace a percentage of lost wages when someone gets hurt on or off the job and suffers a loss of wages.
If your employer provides a group Long Term Disability (LTD) plan, when you become disabled, you should request a copy of the policy immediately or a plan summary. It will include important information, such as filing deadlines, necessary evidence to submit, and a list of qualifying medical conditions. You must be familiar with these terms if you want to file a claim.
Injuries and Illnesses Eligible for Long-Term Disability Coverage
A long-term disability insurance claim refers to a physical, mental, or emotional impairment that prevents a person from working longer than six months. Every policy is different and might contain variations that indicate what is and isn’t considered a disability. Some exclusions could prevent you from collecting benefits if your illness or injury falls under any of those categories.
The Employee Retirement Income Security Act (ERISA) enforces regulations and protects an injured worker’s rights. If your employer provides group LTD disability insurance coverage, the policy will fall under ERISA laws. If you suffer a disabling injury or illness, you can request policy information to help you determine whether you’re eligible for coverage and which benefits you can receive.
Generally, the list of qualifying medical conditions for long-term disability insurance coverage includes the following:
- Vision or hearing loss
- Musculoskeletal disorders, such as back injuries
- Different forms of cancer
- Mental illness, such as anxiety and depression
- Digestive tract conditions, such as inflammatory bowel disease
- Neurological disorders, such as multiple sclerosis and Parkinson’s disease
- Cardiovascular issues
- Skin disorders like dermatitis
- Kidney disease
- Immune system disorders, such as lupus and HIV
- Respiratory illnesses, such as asthma
- Hematological disorders
Steps Involved in a Long-Term Disability Claim
If your employer provides LTD coverage, you can contact their insurance company if your doctor determines that you have a disability and you can’t return to work.
Be sure to notify your employer of your injury or illness promptly. Complete the application provided by the insurance company and submit it to begin the claims process. You should include a statement that provides information, such as:
- Your name and contact information
- Employer name
- Job title
- Employment history
- Medical condition
- Date of disability
- Explanation as to why you’re unable to earn your usual wages
- Medical documentation
Evidence is crucial when you’re applying for LTD benefits. Medical records can prove you have a disability, how it occurred, and the date of diagnosis. Examples of medical documentation you can provide include:
- Emergency and hospital records
- Physician notes
- Imaging reports
- Physical therapy records
- Medical bills
The doctor who diagnosed your disability should also provide a statement for you to include with your application. They should state the injury or illness you sustained and explain the specific physical or mental impairment it caused. It might be beneficial to obtain a copy of your job description to show the tasks you can’t complete.
How Long-Term Disability Payments Work
When you file a claim, there will be an initial elimination period before you’re allowed to collect benefit payments. Policies vary, but most require the disability to last at least six months to qualify for long-term disability coverage. If you return to work before the elimination period ends or you’re able to earn your pre-disability wages, you won’t qualify for benefits.
The payments you receive will depend on your employer’s insurance policy. Most provide between 50 to 80 percent of your pre-injury disability average monthly wages. Other forms of compensation could include things like commissions, bonuses, and overtime as well. You’ll continue to qualify for benefits if you still have a disabling condition until you turn 65 for the time indicated in the plan. In some situations, payments can last a lifetime.
Group Long-Term Disability Benefits
Some employers offer “Long-Term Disability” insurance plans or “LTD” to benefit participating employees who become too disabled to work. Some companies pay the cost of these LTD Plans as a fringe benefit. Other companies offer LTD as an option requiring payroll deductions from an employee’s salary.
Other companies may cover the payment for basic coverage (a disability benefit equal to 50 or 60 percent of earnings) and then offer employees an option to add “supplemental coverage.” Benefits are taxable when paid to the extent that the company pays the premiums. The benefits are tax-free to the extent that the employee pays the premiums.
“Group LTD” benefits paid through a company benefits plan are governed by a federal law known as the Employee Retirement Income Security Act of 1974 (“ERISA”).
An employee is a “participant.” Typically, the employer is the “plan administrator.”
Unless the employer is “self-insured,” LTD claims are more often administered by insurance companies that act as claims administrators and make determinations on claims for LTD benefits. Even self-insured companies may delegate the handling of such claims to a “Third-Party Claims Administrator” to carry out this function and handle all matters relating to such claims.
LTD benefits typically become payable after a 180-day elimination period. In New York State, under the Disability Benefits Law administered by the Workers’ Compensation Board, there is a short-term disability “STD” benefit that pays up to $170.00 per week for 26 weeks. This may prove somewhat helpful when an employee has not accumulated much sick and vacation pay or where the company has no salary continuation plan. Some employers have a supplementary plan that pays a percentage of their salary in addition to the state-mandated amount.
LTD benefits are commonly subject to offsets for government disability benefits, such as workers’ compensation (paid for on-the-job injuries or work-related illnesses) and Social Security disability (paid to the employee and eligible dependents).
Suppose the total of workers’ compensation and Social Security Disability Insurance Benefits payments completely offset the LTD benefit. In that case, LTD plans may pay a minimum benefit, such as $100 or 10% of the gross LTD benefit). The maximum benefit period for LTD typically ends at age 65 or full retirement age for Social Security purposes.
LTD plans and policies typically define “total disability” in two tiers: benefits will be payable for the first 24 months if you cannot perform your occupation’s material and substantial duties. But after the first 24 months, you must prove you cannot do any work to receive benefits.
It may appear that the “any occupation” standard is the same as the standard used for Social Security Disability. Still, Long Term Disability carriers are not required to adopt Social Security determinations. Usually, policy language permits insurers to discount favorable SSD determinations and to render an independent decision. LTD plans that utilize the preferable definition of “total disability” as being the “inability to perform one’s own occupation” are rare.
Most LTD plans will only pay benefits for a maximum of 24 months for disabilities related to mental impairments or what insurers call “self-reported” illnesses such as illnesses like chronic fatigue syndrome, fibromyalgia, and chronic headaches. In physical and mental impairment cases, carriers sometimes pay benefits based on the cognitive impairment and ignore the physical to limit their payouts to only 24 months.
Pre-existing conditions may also limit recovery under an LTD policy. Benefits may be unavailable to those who became disabled within the first 12 months of participation in the plan and had been treated or diagnosed with the same condition during the 90 days before the effective date of your enrollment unless you were previously covered under another employer’s LTD plan immediately preceding your transfer to the current employer’s LTD plan. The current LTD plan has a “continuation of coverage” provision.
Insurers may rely upon the medical opinion of non-examining, in-house, file-reviewing physicians or so-called “independent medical examiners” rather than the claimant’s treating doctor. Thus the dice are loaded against the claimant. Statistically, such review physicians and” not–so–independent” medical examiners rarely find in favor of claimants.
ERISA requires employers to distribute a Summary Plan Description (“SPD”). This is a basic outline of the plan’s coverage provisions in supposedly “simple language” understandable by plan participants. Usually, this language includes “discretionary authority” upon the insurer as claims administrator, which means the insurer or claims administrator has sole discretion to decide if a participant is “disabled” according to plan guidelines.
Unfortunately, such “discretionary authority” makes it extremely difficult to overturn an adverse decision by an insurance company in a court unless the claimant can prove the decision was “arbitrary and capricious:” meaning either the insurer had no evidentiary basis for its decision or its decision was not rationally based upon the evidence.
In the case of a dispute not resolved through the plan’s internal appeals procedures, the law requires you to bring ERISA lawsuits in Federal Courts. But there are no trials. No one testifies in court, and you can’t submit any new evidence. The court will read the lawyers’ briefs, listen to the arguments, and review the evidence in the record.
LTD benefits, once awarded, are subject to periodic reviews to determine whether the disability continues. Such reviews may be purely medical or include vocational re-evaluation or video surveillance.
Individual Disability Insurance Policies
Another type of long-term disability coverage is the individual disability policy (also known as the disability income or “D.I.” policy). These are privately owned policies one would purchase directly from an insurance company. You ordinarily self-pay your premiums and buy insurance for the fixed monthly dollar amount of disability benefits. These policies are not subject to the disadvantages of ERISA.
Limitations on mental or self-reported illnesses are rare in individual policies. Disputes may be litigated in state courts, similar to any other type of breach of contract claim. Trial by jury is available. A disabled claimant and their physicians may testify. Best of all, a preponderance of the evidence wins in state courts.
When purchasing an Individual Insurance policy, you generally get what you pay for. It may be more expensive (but well worth the cost) to insure yourself against an “inability to do your own occupation.”
You can also pay for “guaranteed renewal,” “cost of living adjustments” in benefits, and riders that allow you to purchase additional insurance. For an additional fee, you can also buy a “partial disability benefits rider” to protect you if an injury or illness prevents you from performing some, but not all, the duties of your own occupation. (Incidentally, these “partial disability benefits” – also called “residual disability benefits” – are sometimes available under ERISA plans.)
What is a vested disability pension?
Vested disability pensions are typically part of union disability plans. Once awarded, a vested disability pension can, under enumerated circumstances, pay benefits for life. In contrast to typical “LTD” plans, many, but not all, of the union-sponsored plans will consider you disabled if the Social Security Administration finds you disabled.
Others decide without regard to what Social Security may have said. Most union plans require at least ten years of covered employment (in an industry under that union). They may also require that the disability arose during employment or within a year from the last work date.
Group disability plans for government employees and employees under church plans are commonly excluded from ERISA.
Please see our section on Municipal and Civil Service Disability Pensions for more information.
Why Was My Claim Denied?
When an insurance company reviews a long-term disability claim, they consider various factors. You could face a claim denial if you include inaccurate information or miss an important deadline.
Before you begin the process, you should thoroughly review the policy to ensure you’re eligible for benefits and complete all forms with the correct information regarding your disability. A long-term disability insurance lawyer can handle this process to ensure you submit a solid claim, including the necessary evidence to back your claim and meet all deadlines.
Claims are often denied for the following reasons:
- Lack of qualifying disability: LTD policies contain different definitions for what qualifies as a disability. Your type of injury or illness might be on one policy but excluded from another. When you cannot return to work, request a copy of the policy information immediately. Sometimes, one may have an injury eligible for benefits, but an exclusion might prohibit payment if the injury resulted from specific types of incidents.
- Procedural error: You should always follow all the claim requirements when you begin the process. Take note of filing deadlines, the documentation you must submit, and the forms you must complete. Missing any step could result in a denied claim.
- Missing or incomplete medical records: Medical records can demonstrate that your disability caused limitations. They must clearly state the type of injury or illness you suffered and how it affects your job abilities. If the details aren’t specific or don’t explicitly mention your condition, the insurance company won’t have a reason to move forward with your application.
- Bad faith: Insurance companies sometimes act in bad faith when they’re reviewing LTD claims. Common examples include:
- Refusing to pay benefits listed on the policy
- Denying a claim without providing a valid reason
- Unreasonably delaying the application process
- Failure to perform an adequate investigation into the disability
- Offering a low settlement amount disproportionate to the value of the claim
- Misrepresenting the language or coverage of the policy
- Refusal to comply with the claimant’s request, such as providing a letter explaining the reason for the denial
- Discrepancies: When you submit documentation to the insurance company, they’ll review it to ensure it’s accurate and consistent. If they find discrepancies with your medical treatment, lost wages, disability, or other details, they could deny the claim.
How Fusco, Brandenstein & Rada, P.C. Can Help You File an Appeal
If the insurance company denies your claim for long-term disability insurance, you can file an appeal. The denial letter you receive should include the reason for denying your application and instructions for appealing the decision. The process can be complicated and confusing for anyone who never filed an appeal before. Your New York long-term disability lawyer will handle every aspect of your case.
When you hire us, we can complete the following steps:
- Read the denial letter to determine the reason and if it’s valid.
- Request a copy of your claim file to review.
- Complete the necessary forms to submit to the insurance company.
- Collect evidence that was missing from the initial claim to prove that you have a disability and deserve benefit payments.
- File an administrative appeal. The deadline for submission is 180 days from the denial date.
Fusco, Brandenstein & Rada, P.C. belongs to a national network of lawyers who are experts in Long-Term Disability cases.
Speak to a Dedicated New York Long-Term Disability Lawyer Today
At Fusco, Brandenstein & Rada, P.C., we know the importance of collecting benefit payments promptly. You don’t want to face ongoing financial struggles while waiting for the insurance company to approve your claim. We’ll ensure they treat you fairly and don’t violate your rights under ERISA law. Our legal team will work diligently to reach a favorable outcome and recover the maximum benefits you deserve.
You won’t be in this fight alone. Our long-term disability lawyers will remain by your side throughout your case. Whether you’re filing an initial claim or appealing a denied claim, you can depend on us to guide you. Call us at 516-496-0400 or contact us online if you cannot work due to a disability.
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