During the past few months ProHealth has featured several articles on Long Term Disability Insurance matters, written by Justin Frankel and Jason Newfield, partners at the disability insurance law firm Frankel & Newfield, LLC (www.frankelnewfield.com).
Justin and Jason represent many claimants across the US with fibromyalgia, chronic fatigue syndrome (ME/CFS), and other potentially disabling ‘invisible’ illnesses. They focus their practice on disability insurance matters for policyholders who purchased their policies on their own (Private Disability Insurance) or have Long Term Disability Insurance through their employee benefits program.
Based on the popularity of these articles, it’s clear that many of you are facing issues with your Long Term Disability insurance policies. Accordingly, Frankel & Newfield have provided answers here to some of the basic questions readers have submitted.
REVIEWING THE BASICS…
When Must I File a Claim?
Most policies require that "proof of loss" be provided shortly after a claim occurs (typically 60 to 90 days). When notice is provided later than two or three months after the event, or if a claimant seeks to back date a claim for partial disability benefits, the insurer may take issue with such notice.
Some states have strict rules on timing, so the best practice is to notify the insurer of the claim and provide proof supporting the claim in a timely manner.
What Role Does My Physician Play in a Long Term Disability Insurance Claim?
Working closely with your physician during the claim process can often make the difference in the claim's success or failure. Challenging a decision reached by an insurer, where the insurer merely adopts your own doctor's opinions regarding a true lack of functional impairment, is extremely difficult.
Your attorney should work with your doctor to make sure that he or she understands the importance of their role in the claim process and to ensure that all documents are prepared correctly. (For more on information that is important in physician documentation, see “Avoiding the Disability Claim ‘Brush-Off’ – What You Need to Know.”)
How Much Information Should I Give the Disability Insurance Carrier?
While this runs counter to one’s initial thinking, we are of the opinion that it should be limited to only as much as is necessary to support the claim! Based on our long experience representing policy owners, we take the cynical view that the insurer is often seeking information to be utilized to deny or terminate benefits.
Be very careful in providing any responses to informational requests from the insurer.
The disability insurance company is entitled to information about your occupation, and in partial disability or residual disability cases, is often entitled to financial information.
But again, be careful - the information you provide can and may be used to deny and delay your benefits. (See “Disability Claim? You’re Not Paranoid… They Really Are Watching You.”) This is where the insights of an experienced disability insurance lawyer can make all the difference in the success of your claim.
Do I Need to Suffer a Total Loss of Income to Collect Disability Income Payments?
If you are unable to perform the substantial and material duties of your occupation, under many policies, you do not need to suffer a total loss of income in order to qualify for disability benefits.
Under many Disability Insurance policies, if you are only residually or partially disabled, as opposed to totally disabled, then you must generally suffer a percentage loss of pre-disability income as defined in the policy.
This type of claim will often involve some financial analysis, to determine the benefit calculation as well as the claim onset date. (See “When You Can’t Manage a Full Workload – Partial Disability May Be an Option.”)
What Are My Options if My Claim is Denied, Delayed or Terminated?
If your Disability Insurance policy is a benefit from your employer, it is a Group LTD Policy that is usually governed by ERISA, a federal law with very specific rules about appeals.
You will need to go through an administrative appeal if your claim has been denied (meaning you will have to appeal directly to the insurance company), and you should only do this with the assistance of experienced and aggressive Disability Insurance lawyers. If and when your appeal is denied, and when you have exhausted your administrative remedies, only then are you allowed to proceed to the appropriate court having jurisdiction of your claim.
If you have a Group Policy governed by ERISA, it is extremely important to work with an attorney who understands how to prepare a powerful and persuasive appeal of the claim, since once you are in court, you will be limited to that record that was before the insurer during the administrative appeal.
If you personally purchased a policy, you have a Private Policy that is treated like any other insurance policy in the eyes of the law. These private policies of Disability Insurance do not require internal appeals, and you can pursue litigation or other dispute resolution mechanisms immediately.
It is useful to prevent problems by bringing an experienced law team on board at the start. We work with many private policy owners to resolve disputed claims before commencing a lawsuit.
* To learn more,
Frankel & Newfield
585 Stewart Avenue
Garden City, New York 11530
Note: ProHealth offers this generic information as a service to readers and does not advocate the services of these specific attorneys in any way. The answers to questions are published with the intent to provide general information and are not intended, nor should they be used, as a substitute for legal advice rendered by a professional in the context of a specific situation. Response to questions does not constitute an attorney-client relationship.