By definition, anyone who applies for short-term and long-term disability benefits is in a vulnerable situation. They are sick or injured and unable to work. And they are counting on their disability benefits to help meet their financial needs. Undeniably, it is unbearably hard to fight a debilitating illness or injury and battle with their insurance company at the same time. So, what should a claimant do if their short-term or long-term disability claim is denied?
First, no one who is legitimately disabled should ever surrender and take the insurer’s decision as the final answer. It is understandable when claimants feel hopeless because they likely have never had to challenge an insurance denial before. Fortunately, when a short-term or long-term disability benefit is denied, claimants do not have to challenge an unfair denial on their own. They can get assistance in taking on their insurance company and getting the insurer to back down and pay them the due benefits.
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Short-Term Disability (STD) Benefit Denials
Short-term disability benefits are of short duration – usually 12 or 26 weeks. Although an insurance company may administer the benefits, short-term disability benefits are often funded by employers and pay a percentage of an employee’s salary while they are off work for an extended period due to sickness or injury.
There can be many reasons why a claim might be denied, so the first thing to do when a denial is issued is to ascertain the precise reason for the rejection. In many instances, denials result from miscommunications with doctors’ offices. The denial can be resolved by providing the insurance company with needed documents such as medical records or a doctor’s report that has been requested and may have gone astray.
If the insurer asserts the denial is due to insufficient proof, the denial letter is supposed to explain what additional evidence might be needed for benefits to be paid. Claimants should also request a copy of their claim file, though, to better understand why the insurance company believes the claim is deficient.
Just because additional evidence is provided, no claimant should assume a claim approval is guaranteed. In addition to obtaining an acknowledgment of receipt of the additional evidence, if the evidence is not deemed sufficient by the insurance company, the claimant needs to know right away, so that appeal rights are not lost. Claimants should be especially wary because the failure to be found disabled for the entire short-term disability benefit period might preclude eligibility to receive long-term disability insurance benefits.
Long-Term Disability (LTD) Benefit Denials
Everything stated above regarding short-term disability benefits applies to long-term disability benefit denials as well. However, additional issues could preclude payment of long-term disability benefits even if short-term disability benefits are paid. For example, most short-term disability plans do not exclude claims resulting from pre-existing conditions. Pre-existing conditions are generally conditions for which the claimant has undergone testing, treatment, or taken medications in the months before the effective date of insurance. A pre-existing condition denial concerning long-term disability presents significant challenges.
Another difference between short-term disability and long-term disability benefits provided by an employer is that short-term disability benefits may be considered an employer’s payroll practice and the claim not governed by the Employee Retirement Income Security Act (ERISA). This law impacts all employer-sponsored fringe benefits. Long-term disability benefits provided by employers are almost always deemed subject to ERISA, though. Benefit claims under ERISA are regulated by an extensive set of detailed complex regulations issued by the U.S. Department of Labor. Those regulations explain the timing for claim appeals and give claimants 180 days from the date they receive a denial to submit an appeal. Once the appeal is submitted, it is supposed to be resolved within 45 days, although an extension of p to 45 days is permitted. Claimants have the right to obtain and comment on any evidence amassed by the insurance company. Claimants are also allowed to submit new evidence to challenge the basis of the denial.
Checklist for Both Short-Term and Long-Term Disability Benefit Denials
If you have received a denial, here’s what you should do:
- Don’t panic – the decision isn’t final and is subject to challenge.
- Don’t delay – there are time rigid frames that govern claim appeals. A deadline of 180 days seems a long time, but it isn’t when you need to collect additional evidence
- Get help immediately – disability benefit claims are complex, as are the federal regulations governing ERISA claims. Most claimants cannot read and understand medical records and test results; and are also unfamiliar with many vocational issues that arise in disability insurance claims. Furthermore, a misstep during the claim appeal process can potentially be fatal to the success of an ensuing lawsuit.
While the claims process should be simple enough for a claimant to handle, the claim appeal is itself a complex legal process. No layperson should represent themselves if they need to appear in court. While the appeal process doesn’t take place in a courtroom, it can be just as daunting a process to navigate.
- Get the right help – very few lawyers have experience with ERISA claims. If you have been denied disability benefits, you need to find counsel with the experience and know-how to address your situation rather than a friend or relative who offers to lend a helping hand. Claimants should do their homework when they seek out an attorney and not just pick the first name that shows up in a Google search. Most lawyers and law firms have websites that describe their experience and knowledge. Spend the time to research to find the right lawyer who has proven courtroom experience.
Turn to an Experienced Benefits Counsel to Challenge STD or LTD Denials
When a short-term or long-term disability benefits claimant receives a claim denial, they often don’t know where to turn. Fortunately, all is not lost, nor is the situation by any means hopeless. If you have experienced a denial of your short-term or long-term disability claim, help is available. While the denial may be easily fixed, it would be a mistake to assume that a mistake was made that can be resolved with a simple phone call or an additional note from a doctor.
Instead, anyone who has received a denial of their short-term or long-term disability claim should immediately turn to experienced and knowledgeable counsel for support to challenge the denial by submitting an appeal. They could then take the case to court if an appeal is unsuccessful.