When you’re unable to earn a living, you’re in a vulnerable position. We know you’re worried about your finances and wondering how you’re going to afford medical treatment. We’ll protect your rights and use our knowledge of the state laws to ensure you receive the maximum payments you need.

When you’re treating a disability, there are options to supplement 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 find out 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 New York long-term disability attorneys.

What is the difference between workers’ compensation and long-term disability?

Many people misunderstand the differences between long-term disability (LTD) benefits and workers’ compensation coverage. People sometimes use the terms interchangeably, but these are different types of insurance plans. Workers’ comp provides multiple benefits for anyone who suffers a work-related injury or illness, while 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 plan summary. It will include important information, such as filing deadlines, necessary evidence to submit, and a list of qualifying medical conditions. You will need to 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 for a period longer than six months. Every policy is different and might contain variations that indicate what is and isn’t considered a disability. There are also exclusions that 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 are able to receive.

Generally, the list of qualifying medical conditions for long-term disability insurance coverage includes:

  • 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 includes:

  • Emergency and hospital records
  • Physician notes
  • Imaging reports
  • Physical therapy records
  • Medical bills

The doctor that 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 what’s listed on your employer’s insurance policy. Most provide somewhere between 50% to 80% of your pre-injury disability average monthly wages. Other forms of compensation could include things like commission, bonuses, and overtime as well. You’ll continue to qualify for benefits as long as you still have a disabling condition up until you turn 65 years old for the period of 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” designed to provide benefits to 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. Some companies may cover the payment for basic coverage, (which may be a disability benefit equal to 50% or 60% of earnings), and then offer employees an option to add “supplemental coverage.” To the extent that the company pays the premiums, benefits are taxable when paid. To the extent that the employee pays the premiums, the benefits are tax free.

“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 which act 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 which 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 paying a percentage of salary in addition to the state mandated amount.

LTD benefits are commonly subject to offsets for government disability benefits, such as Workers’ Compensation benefits (paid for on-the-job injuries or work-related illnesses) and Social Security disability (paid to the employee as well eligible dependents). If the total of Workers’ Compensation and Social Security Disability Insurance Benefits payments end-up completely offsetting the LTD benefit, LTD plans may pay minimum benefit, such as $100 or 10% of the gross LTD benefit). The maximum benefit period for LTD typically ends at age 65 or at one’s full retirement age for Social Security purposes.

LTD plans and policies typically define “total disability” in two tiers: for the first 24 months benefits will be payable if you are unable to perform the material and substantial duties of your own occupation; but after the first 24 months you must prove that you are disabled for any occupation.

It may appear the “any occupation” standard is the same as the standard used by Social Security Disability, but 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 their own independent determination. LTD plans that utilize the more 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 cases involving physical and mental impairments, carriers have been known pay benefits based on the mental impairment and ignore the physical, in an effort to limit their pay-outs to only 24 months.

Pre-existing conditions may also limit recovery under an LTD policy. Recovery may be barred to those who become disabled within the first 12 months of participation in the plan and had been treated or diagnosed with the same condition during the 90-day period prior to 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 and the current LTD plan has a “continuation of coverage” provision.

Insurers may rely upon the medical opinion of non-examining, in-house, file-reviewing physician or a 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 plans internal appeals procedures the law requires that ERISA lawsuits must be brought in Federal Courts. But there are to no trials. No one testifies in court and no new evidence may be submitted. 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 in nature or may 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 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 his or her physicians may testify. Best of all, in state courts a preponderance of the evidence wins.

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 get “guaranteed renewal,” “cost of living adjustments” in benefits, and riders that allow you to purchase additional insurance. For an additional fees you can also purchase 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 found in 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 make their own decision without regard to what Social Security may have decided. Most union plans require at least 10 years of covered employment (in an industry covered by that union). They may also require that the disability has arisen either during the course of employment or within a year from last date of employment.

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. If you include inaccurate information, or missed an important deadline, the claim could be denied.

Before you begin the process, you should thoroughly review the policy to ensure you’re eligible for benefits and complete all forms with all of the correct information regarding your disability. A long-term disability insurance attorney can handle this process for you to ensure that you’re submitting a solid claim, including the necessary evidence to back your claim, and meeting all deadlines.

Claims are often denied for the following reasons:

Definition of disability: LTD policies contain different definitions for what qualifies as a disability. Your type of injury or illness might be included on one policy, but be excluded on another. When you’re unable to return to your job, request a copy of the policy information immediately. Sometimes, one may have an injury eligible for benefits, but there might be an exclusion that prohibits 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 are required to submit, and the forms you need to 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 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 on the policy
  • Refusal to comply with claimant’s request, such as providing a letter explaining the reason for 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 denied your claim for long term disability insurance, you have the right to 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 attorney will handle every aspect of your case.

When you hire us, we can complete the following steps:

  1. Read the denial letter to determine the reason and if it’s valid.
  2. Request a copy of your claim file to review.
  3. Complete the necessary forms to submit to the insurance company.
  4. Collect evidence that was missing from the initial claim to prove that you have a disability and deserve benefit payments.
  5. 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 attorneys who specialize in Long Term Disability cases.

Speak to a Dedicated New York Long-Term Disability Attorney 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 you’re 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. We’ll 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 through the process. Call us at 516-496-0400 if you’re unable to work due to your disability.

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