Have you been diagnosed with a severe medical or mental health condition, or sustained a serious injury, and are considering ceasing working and applying for disability insurance benefits? Have you already stopped working and applied for disability insurance benefits, but your claim was denied? Maybe you stopped working and were receiving disability insurance benefits, but the benefits were terminated before you were released to go back to work by your doctors? If so, the Seattle disability lawyers at DeBofsky Law can help.
What Are the Different Types of Disability Insurance Benefits?
Disability insurance protects your income in the event you become disabled and can no longer work. While many employers sponsor group disability benefit plans for their employees – in which case the benefits are commonly referred to as short-term disability (STD) and long-term disability (LTD) benefits – some employers do not. If your employer does not offer disability coverage or you are self-employed, you can purchase individual disability insurance (IDI) on your own.
Short Term Disability (STD) & Long Term Disability (LTD)
Many employer-sponsored disability benefits plans will cover short-term disability benefits (STD) for the first three to six months you are out of work, and then long-term disability (LTD) benefits for those conditions and injuries lasting for more extended periods. LTD benefits are typically payable until you reach retirement age.
STD and LTD benefits are typically paid based on a percentage of your pre-disability monthly income, such as 60% or 66.67%. Employer-sponsored disability benefits are also often coordinated with other benefits you may be eligible to receive, such as Social Security disability benefits.
Individual Disability Insurance (IDI)
You can purchase individual disability insurance (IDI) on your own if you:
- Are self-employed;
- Work for an employer that does not offer disability insurance; or
- Have disability insurance through your employer that only covers a small portion of your income.
IDI policies typically pay a defined monthly benefit amount based on your pre-disability earnings.
What Laws Apply to Disability Insurance Benefits?
If you work for a private-sector employer that offers disability insurance, your benefits are likely governed by the federal benefits law called the Employee Retirement Income Security Act of 1974 (ERISA). If you work for a government or church-related entity, your benefits are exempted from ERISA coverage. If you purchased your own disability insurance policy, your benefits are governed by the State of Washington’s bad faith insurance laws.
What Does the Disability Insurance Benefits Claim Process Entail?
The disability insurance benefits claim process starts with an application for benefits, typically initiated by requesting and completing claim forms supplied by your employer, plan administrator, and/or insurance company. As part of your application, you may need to produce supplemental documentation, including, but not limited to, your treatment records, job description and/or resume, and earnings records. If your claim is approved, then you should start receiving benefits on a weekly or monthly basis once you satisfy your plan’s elimination period.
Unfortunately, though, short-term disability (STD), long-term disability (LTD), and individual disability insurance (IDI) benefits claims are denied all the time. Some common reasons why disability insurance benefits claims are denied include that you no longer qualify for coverage under your plan, your disability is subject to an exclusion and/or limitation in the plan, or your medical condition is not severe enough to prevent you from working and meet the definition of “total disability” under your plan.
If your disability insurance benefits claim is denied, you will likely have to appeal the denial to the plan administrator and/or insurance company. You will typically have up to six months to prepare and submit your appeal, and then the plan administrator will typically have up to three months to render its decision. However, certain types of disability benefit claims will be subject to different timeframes. If the denial of benefits is maintained after you submit your appeal, you can then file a lawsuit seeking the benefits due, along with the attorneys’ fees and costs incurred in litigation.
Please refer to the following blog article for more detailed information regarding the disability insurance benefits claim process: What Should I Expect When I File a Disability Insurance Claim?
How Do You Qualify for Disability Insurance Benefits?
You will typically be eligible for short-term disability (STD), long-term disability (LTD), or individual disability insurance (IDI) benefits if you suffer from a severe illness, injury, or mental health condition that impacts your ability to work. If you are disabled and cannot work in any capacity, you may qualify for total disability benefits. On the other hand, if you have a disability, but can still work in a limited capacity, you may qualify for residual disability benefits. In that case, you will be paid a percentage of the total disability benefit amount you would otherwise be eligible to receive, which will be calculated based on the extent of your disability and loss of income.
Some disability benefits plans will define disability based on whether you can continue to perform your regular occupation, while others will include an any reasonable occupation standard. It is also very common for LTD benefit plans to include an “own occupation” standard initially, but have the definition of disability transition to an “any occupation” standard after a set period of time (typically between 12 to 36 months).
To qualify for disability insurance benefits, you will also need to meet certain requirements, including ensuring:
- Your disability coverage remained active and in force when you ceased working or reduced your work schedule;
- You are under the regular care of a doctor or other medical professionals with the appropriate specialty to treat your condition;
- You can provide documentation of how your medical or mental health condition results in work-related restrictions and limitations; and
- Your condition does not fall into an exclusion under the plan, such as for pre-existing conditions or self-inflicted injuries.
What Medical Conditions Qualify for Disability Insurance Benefits?
You can qualify for disability insurance benefits based on various medical and mental health conditions. Common mental health conditions that may cause a disability include, but are not limited to:
- Borderline personality disorder
- Bipolar disorder
- Post-traumatic stress disorder (PTSD)
- Substance use disorders
While most disability plans pay benefits for as long as you remain unable to work until you reach normal retirement age, disability benefits for mental illnesses and substance use disorders are often limited to a shorter payment period up to a maximum period of typically 24 or 36 months. Please refer our Mental Health Disability page for more information on mental health disabilities.
Common types of medical conditions that may qualify for disability insurance benefits include, but are not limited to:
- Multiple sclerosis (MS)
- Spinal impairments
- Chronic pain
- Chronic fatigue syndrome
- Sleep disorders
- Vision impairments
Many people also qualify for disability insurance benefits based on cognitive disorders, which may be classified as either a mental health or medical condition depending on the terms of your plan.
Know Your Rights
You are potentially eligible for many different kinds of disability compensation, including:
- Retroactive (past-due) benefits
- Future benefits
- Interest paid on past-due benefits
- Attorney’s fees
Work with attorneys who know how to get you everything you deserve.
Does This Apply to You?
Contact DeBofsky Law for an attorney consultation. We will work with you to figure out your problem, and how we can help.
Why Do Insurers Deny Disability Insurance Benefits Claims?
There are many reasons why an insurance company may deny your claim for disability insurance benefits. The insurer and/or plan administrator may allege that you have not provided adequate proof of your disability or dispute that your injury or illness is severe enough to prevent you from working. Your claim for short-term disability (STD), long-term disability (LTD), or individual disability insurance (IDI) benefits may also be denied based on an exclusion or limitation in your plan, or because your coverage lapsed before you ceased working. Whatever reason(s) are provided as the basis for the denial of your claim, you have options, but it is crucial that you consult with experienced legal counsel like the attorneys at DeBofsky Law.
Please refer to the following blog article for a more detailed discussion of the common reasons disability insurance benefits claims are denied: Why Do Disability Claims Get Denied?
What Are Your Options if Your Disability Insurance Benefits Claim Is Denied?
If you receive disability insurance coverage through a private-sector employer, your claim will be governed by the federal benefits law called the Employee Retirement Income Security Act of 1974 or ERISA. On the other hand, individual disability insurance policies are governed by Washington state law. If you have submitted a claim for disability benefits and it was denied, you will likely need to submit an internal appeal to the insurance company and/or plan administrator. If your appeal is also denied, you will then be able to pursue further legal relief in court.
The ERISA statute contains specific enforcement and remedial provisions for denied benefit claims, and those cases are typically brought in federal court. If your claim is governed by ERISA, you will only be able to collect the benefits due and your reasonable attorneys’ fees and costs incurred in litigation. On the other hand, individual disability insurance disputes are pursued as a breach of contract claims in either state or federal court. Washington state insurance law also provides for bad faith damages.
Do You Need a Lawyer to Get Disability Insurance Benefits?
You do not need to be represented by counsel to get disability insurance benefits, but it may be prudent to hire a lawyer even to assist with the application process. For one thing, the terms and conditions that apply to your claim will depend on the particular provisions of your plan, which can be complicated. For example, most group disability benefits plans contain exclusions for “pre-existing conditions,” which are disabilities related to a medical condition that existed before you were covered under the plan if you cease working within the first year of your coverage becoming effective. Most disability benefit plans also only pay benefits for limited periods for specific types of disabilities, such as those caused by a mental illness, substance use disorder, or “self-reported” condition.
Accordingly, it can be crucial that you consult with an experienced disability benefits attorney who can review your plan and advise you of its specific terms and conditions before starting the application process. If you decide to apply for disability insurance benefits on your own and the claim is denied, or your claim is initially approved, but the benefits are terminated prematurely, then it is critical that you consult with experienced legal counsel right away.
Please refer to the following blog article for more information regarding common mistakes made by claimants when navigating the claim process on their own: What Are the Top Mistakes Disability Insurance Claimants Make When Seeking Disability benefits?
How Can a Lawyer Help with your disability insurance benefits claim?
An attorney can advise you on the specific terms of your plan, instruct you on how to complete the claim forms, and navigate you through the entire claim process. Even if you decide to apply for disability insurance benefits on your own, and your claim is denied, or your benefits are later terminated, you should consult with a lawyer as soon as possible. If your disability benefits are denied or terminated, then you will likely need to submit an appeal to the insurance company and/or plan administrator. The appeal must be submitted before you can file a lawsuit in court, and there are strict timing deadlines that apply.
Additionally, in most cases, you will not be allowed to introduce new evidence in court if your appeal is unsuccessful, and you must initiate litigation against the insurer and/or administrator. As a result, you must use the appeal process to ensure there is a complete record for the court to review, if necessary. Otherwise, the insurance company and/or administrator can fill the file with evidence biased against you and not reflective of your disability. Some examples include covert surveillance footage or medical reviews performed by doctors who never even examined you. An attorney specialized in disability benefits issues, ERISA, and Washington bad faith law can assist you in ensuring that you have provided sufficient documentation and other evidence to support your disability benefits claim.
Please refer to the following blog article for further guidance on when best to hire a disability insurance benefits lawyer: When Is the Right Time to Hire a Disability Benefits Attorney?
What to Look for When Choosing a Seattle Disability Insurance Benefits Attorney
Hiring counsel to represent you while you seek disability insurance benefits can maximize your chances of getting your claim approved. Therefore, it is essential that you select experienced benefits counsel who can advise you through every step of the process, educate you on the specific terms of your plan, and familiarize you with the business practices of the large insurance companies and third-party administrators. You will want to select a law firm that knows the ins and outs of each carrier’s practices, the internal claim and appeal process, and the court system to fiercely defend your legal rights and benefits. You will also want counsel that is sympathetic, empathetic, and patient while you navigate this difficult transition period, so you can focus on what matters most, which is your health.
Please refer to the following blog article for additional details regarding what to look for when hiring a disability insurance benefits attorney: What to Expect When Hiring a Lawyer for a Disability Insurance Claim.
Top-rated Seattle Disability Benefits Law Firm
If you have disability insurance, can no longer work, and are considering filing a claim for disability benefits, or you already submitted a claim for disability benefits, but it was denied, you may need to consult with an attorney. Our firm handles most disability insurance benefits denials on a contingency fee basis at both the appeals and litigation phases. That means you do not have to pay a fee (besides your out-of-pocket costs) unless we win or settle your case. We also offer hourly and flat fee arrangements in certain circumstances.
The disability and bad faith insurance attorneys at DeBofsky Law are here to help you protect the benefits you are entitled to receive. You and/or your employer have been paying premiums on your disability insurance policy, and the attorneys at DeBofsky Law will ensure that the insurance company also lives up to its end of the bargain and pays you the disability benefits you deserve. That way, you can protect your finances and focus on improving your health.
Call DeBofsky Law, Seattle’s top-rated disability insurance benefits lawyers, for a confidential consultation now.
Our Recent Victories
We know the tricks insurers and plan administrators use to deny claims. We’re here to fight on your behalf. See How We’ve Won Your Rights.
Robinson v. Aetna Life Ins. Co.
Some disability plans require plaintiffs to receive Social Security benefits within 24 months of initially qualifying for long-term disability benefits or no further benefits are payable. In this ruling, the court declined to dismiss the complaint due to a tardy SSDI approval, deeming such a denial to be arbitrary and capricious.
Disabilities Policies ERISA Ruling
Hennen v. Metro Life Insurance
DeBofsky Law, recently won a remand from the U.S. Court of Appeals for the Seventh Circuit in Hennen v. Metro. Life Ins. Co. Susan Hennen suffered from chronic low back pain radiating into her legs, despite having undergone three back surgeries…
Fibromyalgia ERISA Ruling
Cathleen Kennedy v. Eli Lilly & Co.
DeBofsky Law, along with Bridget O’Ryan and O’Ryan Law Offices won a victory in the U.S. Court of Appeals for the Seventh Circuit on May 18, 2017 in the case of Cathleen Kennedy v. Eli Lilly & Co. The case involved a disability benefit claim…
“I could not have made it through without you.”
“Thank you so much for helping me. I apologize for being a complete, frantic, panicked client. I know my cognitive issues were not helpful in trying to work through this scary and often unfair process. And with no one around me understanding the process; that was no help either. I appreciate your compassion, understanding + help. I could not have made it through without you. I think I would have quit + given up many times.”
Jen H | Client
Learn More About Disability Law to Protect Your Rights
How Do Insurance Companies Evaluate Short-Term and Long-Term Disability Claims?
Both short-term and long-term disability claims are evaluated using a variety of factors to determine if an individual is eligible to receive benefits. […]
How Long Does it Take to Appeal a Disability Insurance Benefits Denial?
Disability insurance benefits can protect you and your family from financial hardship by insuring a portion of your income for so long as you remain out of work due to an injury or illness. The disability benefits process can be complicated, particularly if your claim is denied or your benefits are prematurely terminated, so it is essential that you understand your rights and obligations in order to maintain the viability of your claim. […]
Depression Due to Physical Impairments Can Place Disability Claimants in a Catch-22
If you suffer from chronic pain, fatigue, and other symptoms severe enough to interfere with work, there is a good chance you also suffer from depression, anxiety, and other mental health problems. […]