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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 private policy?
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 plan documents.

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.