When must I file my short-term or long-term disability claim?
As soon as possible! Different disability plans have different requirements,
but the safest approach is to make your claim, in writing, to the claims
administrator, while you are still technically employed or on FMLA (Family
Medical Leave Act) or other authorized leave. If you cannot work, you
may be able to protect yourself by asking for protection under the FMLA
and then requesting short-term and
long-term disability. Most importantly, while you are still employed, call ERISA Law Center
to assist you in making a timely request.
How is an ERISA group disability policy different from an individual or
ERISA group policies are obtained by an employer for the benefit of its
employees, although the employee may pay part or all of the premium. Individual
or private policies are purchased by individuals for themselves. Employees
of disability insurance companies sometimes confuse the two and many non-ERISA
lawyers may not be aware of the distinction. It is critical that you consult
a qualified ERISA attorney to help you learn the difference between group
and private policies.
What are short-term versus long-term disability benefits?
When an employee becomes disabled and seeks disability benefits through
his or her employer, the first available benefits are often short-term
disability benefits. A few states provide state disability benefits, which
may supersede or supplement short-term benefits. After the period of time
defined in the short-term plan, often 90-365 days, short-term benefits
can transition into long-term benefits, which generally last until age
65 (or whatever age your policy states), or the employee’s normal
Social Security retirement age, assuming the employee remains disabled.
Do I have to receive all my short-term disability benefits in order to
receive long-term benefits?
This question can only be answered by reviewing your disability plans.
Many insurance companies and human relations departments will take the
position that without completion of short term benefits, long term benefits
are not available. An examination of many plans reveals this to be incorrect.
Most plans require that you be “qualified” to receive short
term benefits before applying for long term benefits. But some plans do
require that you receive all possible short term benefits in order to
be eligible for long term benefits.
What is a “discretionary clause” in a disability policy?
Most policies and plans reserve “discretion” to the administrator
or insurance company to interpret the plan and decide claims. When discretion
is reserved, courts are obligated to defer to the insurance company’s
or plan’s decision unless it is “arbitrary and capricious,”
a highly deferential standard. The effect of a discretionary clause in
disability plan can often result in a strong legal preference for the
insurance company in court. Discretionary review is contrasted to “de
novo” review, which results from the absence or invalidation of
discretionary authority. Discretionary clauses in insurance policies (but
not in self-insured plans) are now outlawed, to a certain extent, in many
states, including California, Illinois, Maryland, Washington, Minnesota,
Michigan and Texas. A qualified ERISA lawyer can help you identify which
standard applies to your policy and how to take advantage of recent laws
outlawing discretionary clauses.
What is a “remand”?
When a judge decides an ERISA disability case, he or she may either grant
or deny reinstatement of benefits. The judge may also remand the case
back to the claims administrator to review additional records, conduct
new tests on the claimant, or re-review the entire file in light of a
particular ruling by the court.
What are pre-existing conditions and how can they affect my benefits?
Pre-existing conditions are those medical conditions which pre-date enrollment
in a disability plan which can, by the terms of the plan, be excluded
from coverage if they result in disability. The determination whether
a particular condition is “pre-existing” under the terms of
the plan is a legal determination best made by an experienced ERISA attorney.
When a disability insurance company makes benefit payments under a “reservation
of rights,” what does that mean?
This means that the plan and/or insurance company has not yet made a final
determination on whether benefits should be paid. Therefore, since the
review process may have already been delayed, the plan agrees to pay benefits
with its final determination to be made in the future. It is worth noting
that if payments are made under a reservation of rights, the plan or insurance
company may have the right to seek the return of the benefits if its ultimate
decision is not in your favor.
Where can I get a copy of my long-term disability policy, and do they have
to give it to me?
Your employer or plan administrator should have a copy of your disability
plans. You need to make your request in writing. It also helps to remind
your employer (or the plan administrator, if one is identified) that your
request must be satisfied within 30 days or courts may impose a sanction
of $110 per day for every day the administrator fails to provide such
What is “own occupation” versus “any occupation”?
Generally, disability plans or waiver of premium plans define disability
as “the inability, though accident or injury, to perform the substantial
and material duties of one’s own occupation.” Usually after
two years (sometimes longer or shorter), most plans convert that definition
to “…to perform the substantial and material duties of any
occupation, based on background, training, and experience.” As you
can see, the own occupation definition is easier to qualify for than the
any occupation definition, because your particular job probably involves
particular intellectual, physical, or stress-related demands which are
greater than those of any occupation. It is particularly important to
consult with an ERISA attorney as to the proper definition because some
states impose requirements that may require insurance companies to redefine
these definitions in a more consumer-friendly way.
If I become disabled after age 60, for how long can I receive disability benefits?
Without access to your plan, that answer is hard to provide. Most plans
limit disability benefits to age 65 or normal Social Security retirement
age. On the other hand, some plans provide that if the claimant has already
reached the age of 60 when he or she applies for disability, benefits
continue to age 66, 67, or beyond. Additionally, while you may be entitled
to disability benefits at age 60, your right to certain retirement benefits
may reduce (or even eliminate) the amount of disability benefits to which
you may be entitled. An experienced disability lawyer can provide you
direction on this issue.
Get immediate, experienced help with your disability or life insurance
claim. Call (844) 710-2993 today.