Q & A with insurance lawyer Glenn Kantor
Written by Kantor and Kantor insurance Matters on May 6, 2013
Becoming knowledgeable about the claims process can help you advocate for the disability benefits to which you are entitled. Understand that in order to be eligible for Long Term Disability benefits, you must (1) be covered under the terms of your plan, and (2) satisfy the plan’s definition of total disability. Unfortunately, even if your Plan provides you with disability benefits and you meet their definition for disability, your insurer can still find ways to deny your claim. Below are questions that Kantor & Kantor frequently encounters when dealing with disability claims and insurance denials.
How do I know if I have Long Term Disability (LTD) benefits? Or more importantly, who should I ask? Firstly, find out if you have LTD benefits. For those of you who did not purchase a disability policy independently, the answer is a little bit more complicated. If your employer has provided you with a package of insurance services, it might not be immediately clear whether or not LTD is included. In this case, you (or your attorney) can send a certified letter to your employer, requesting a Summary Plan Description and all Benefit Plans provided by your employer.
What if my employer will not provide the Summary Plan Description or Benefit Plan information? You should know that upon written request, your employer (or the Plan Administrator) is obligated under Federal Law to provide you with information regarding benefit programs within 30 days! When submitting your request, be sure to do this by certified mail so that your employer cannot deny having received it. If they fail to provide this information on a timely basis, they can be subject to penalties.
How do I submit a LTD Claim? Once you have a copy of your Summary Plan Description and/or the policy, you can refer to the policy for the specific claims submission procedure implemented by your employer. The steps for submitting a claim can vary depending on your employer, however, the process usually begins when you contact your employer or insurer to tell them that you need to submit a disability claim. You will then be provided with a number of forms to complete and sign for your claim. Make sure that you complete ALL required forms…failure to do so will most likely result in a denial for “failure of proof”.
What types of paperwork should I expect to receive?
1. Disability Claim Form: state the reasons that you are disabled and identify your treating physicians.
2. Attending Physician Statement: this will be completed by your treating physician. He/she will state your restrictions and limitations, which prevent you from performing the material duties of your occupation (and the expected duration of your condition).
3. Employer’s Statement: this will be completed by your employer, identifying your rate of pay and job responsibilities at the time of your ceased employment.
4. Authorization of Release of Medical Information: this form will allow the Claims Administrator to obtain your medical records.
5. Additional Information: take advantage of this opportunity to submit additional documentation in support of your claim. For example, records from your treating physician that support your diagnosis and disability, a detailed job description which describes your work duties (including the physical and mental demands and the working hours required), a letter from you describing the symptoms of your disability and how this impacts your functional capacity for work and daily living, and letters from family, co-workers, or friends describing their personal observations of your symptoms and how this has adversely impacted you at work and home.
How should I communicate with the Claims Administrator? All communication with your insurance company should be in writing! All correspondence should be sent through certified mail, return receipt requested.
What should I do if my claim has been denied? Under the Employee Retirement Income Security Act (ERISA), you have a legal right to appeal the denial of disability benefits.A simple place to begin would be to request your claim file and policy from your insurance company. The claim file consists of: all medical records, reviewed internal notes and memos, outside doctor reviews, surveillance video and any other information the insurance company used to make a decision on your claim.
The appeal creates yet another opportunity to provide the insurance company with evidence of your disability. Gather thorough explanations from your physician, family members/friends, and employer on how your disability has impacted the quality of your daily living. Also, do not ignore the side-effects of the treatment of your disabilities, and how those impact your ability to work. The more people you have explaining your limitations and restrictions, and how your life has been adversely impacted by your illness, the stronger your claim becomes.
Make your appeal letter similar to a cover letter, telling the insurance company why you disagree with their decision, and what information they will find in your appeal packet (the information mentioned above) that will change their minds. Remember, any information you leave out of your appeal may never be heard or considered by a court! Carefully consider all of the information you would like to include before sending through certified mail, fax or e-mail.
Keep in mind that claims have time limits governing the claim and appeal process. According to the Regulations, a claimant has a minimum of 180 days to appeal a denied disability claim. An insurer must decide the appeal within 45 days, or if “exceptional circumstances,” exist, may request an additional 45 day period to decide the appeal.
This process is becoming too complicated for me to manage on my own. What should I do if I need assistance?
Communicating with insurance companies can be a tedious and exhausting venture. The stress from dealing with a Long Term Disability denial only adds to the difficulty of living with chronic illness. If you have questions about your LTD insurance denial, Kantor & Kantor can help. We offer no cost consultations, and we work on a contingency basis–meaning we do not collect a fee unless we get your claim paid. See our website for more information or call us at (800) 446-7529. We can help.