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Can I Appeal My Long-Term Disability Claim?


Applying for and having long-term disability claims approved for benefits can be difficult. It can be hard to work with insurance companies. It can be helpful to learn about your long-term disability policy and try to avoid common mistakes that can prevent you from receiving benefits. If your claim gets denied, appealing that decision and continuing to fight for your rights is your next step.

If you have received a denial from your insurance company, the first thing to understand is that this response is quite common. Before you meet with a lawyer to discuss your case, be sure to carefully review the denial letter and request insurance policy documents, specifically the summary plan description, and have both ready when you schedule your legal consultation.

Appealing a denial via the insurance company’s internal policies is the first step toward redressing the denial. However, if you have provided the insurance company with everything you have, the result will likely be the same.

If not already provided, persuasive evidence to present on appeal can be medical records and letters from medical professionals who have treated your long-term disability. Other evidence could include expert testimony where a medical professional or academic instructor shares his or her professional opinion on your condition.

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Contacting a lawyer for clarity and support when appealing claims can not only help your case move forward successfully, but also can alleviate some of the stress that is associated with trying to file an appeal on your own.

Can I Sue My Insurance Company for Denying My Long-Term Disability Claim?

Acting quickly after a claim is denied is the best way to try to receive the benefits that are due to you. Once you receive a denial, you can file an appeal, but there is a short period of time in which you can sue your insurance company for non-payment of benefits. This “limitation period” is specific, so immediate action is necessary. Calculating the limitation period, or how long you have to file a lawsuit, can be complicated since each case requires its own review of circumstances and appropriate shifts in timing. Importantly, an appeal of the denial does not pause the clock on the limitation period, so even if you are moving forward with disputing the denial, simultaneous work should commence on a lawsuit.

Generally, a two-year limitation period is the length of time allowed to file a long term disability claim from the date of denial, but not always. We would recommend a Statement of Claim be issued before the one-year anniversary of the initial denial. Unfortunately, if timing rules are not carefully followed, your case could suffer.

Not every instance of a denial of a claim will need to be followed with a lawsuit. To understand how your individual case might or might not be supported by filing suit against your insurance company, contact us today for a free consultation to learn more. Developing a legal strategy to ensure that you receive the benefits that you are entitled to is our ultimate goal.

What Can I Do if My Insurance Claim Is Denied?

After your claim is denied, try first to clearly understand why the insurance company denied your request. Claims can be denied for many reasons like inaccurate insurance information, incomplete recording of medical tests or procedures, or insufficient medical necessity. By contacting your doctor, insurance company, or hospital as soon as you receive your denial, you can take steps toward building an appeal that will address the concerns of the insurance company.

Next, it is important to ask for help. By enlisting the support and advocacy of doctors, medical professionals and vocational experts, you can build a coalition of people ready to help you demonstrate to the insurance company the full nature of your disability.

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Reaching out to those on your medical team can at times correct logistical issues that might have hurt your initial claim. For example, if your claim was denied due to incomplete recordkeeping, then your doctor may simply need to clarify or correct the initial claim submission.

Throughout the course of your claim, it is important to keep every piece of correspondence.

What Is a preexisting condition?

A preexisting condition is a health problem that you had before health coverage begins. Usually, you have sought treatment for this condition in the past.

Insurance companies ask about what condition you may have so that they have a clear understanding of how much risk is associated with providing you coverage. When applying for a new plan, you might be asked to complete a questionnaire about your health. Insurance companies want to understand if you have a condition that might require a significant amount of treatment because it would cost the company more to keep you insured.

Preexisting medical conditions can be either mild or severe. Many people cope with mild conditions, like asthma or diabetes, that are easy to manage and do not have an immediately life-threatening impact. These conditions will almost never impact your ability to receive the insurance coverage you want.

While you will still be eligible for insurance coverage, you may have to pay a higher premium and may need to submit to some medical tests before you are coverage is approved.

On the other hand, if you suffer from a serious pre-existing medical conditions like heart disease, stroke or cancer, you may have a more difficult time finding coverage that works for you. Policies can usually be purchased after a certain length of time has passed in remission or recovery.

One other note is how to distinguish a preexisting medical condition from a recording of your family’s medical history. When disclosed to insurance companies, your family history might affect the cost of your premium, but will not bar you from coverage.

Insurers may deny your claim for long-term disability benefits if you make a claim for a disability that you denied having in your application.

How Do I Get Approved for Long-Term Disability Benefits?

First, you should review the types of benefit plans and programs to figure out where you qualify. Each plan sets out different criteria for eligibility. Keep in mind that you might be eligible for more than one option. Long-term disability insurance benefits are intended to pay disability replacement income for several years, so depending on your plan, that could mean payments until the age of 65.

To be eligible for these benefits, you must be covered under a disability plan or insurance policy. Generally, a person is eligible to apply for long-term disability benefits if the disability was the result of an illness or accident. If the disability was caused by a workplace accident, then the long-term disability benefits would overlap or conflict with workers’ compensation benefits.

Another interesting option to talk with your lawyer about is your eligibility under the Canada Pension Plan Disability, which provides payments if you are under the age 65, unable to maintain gainful employment due to disability, and have made recent contributions to the Canada Pension Plan.

After you have chosen that you wish to pursue a claim, it is important to talk with your doctors to ensure that they will help you as you move through the process by providing medical records and statements of your condition to insurance companies or other necessary parties.

It is also important to develop and work through a plan with your employer to make the transition from working full time to taking sick leave to ultimately being unable to work any longer. Having your employer understand your condition can be helpful to both your health and your claim.

Finally, complete all necessary forms and applications with a skilled lawyer who is ready to fight to make sure that you receive the benefits you deserve.

Is Addiction a Disability?

The question of treating addiction as a disability has been hotly debated during the last decade.

For example, on September 16, 2010, the Ontario Court of Appeal ruled that individuals are entitled to long-term disability benefits under the Ontario Disability Support Program Act (ODSPA) because of dependence on alcohol and drugs.

Addiction, like any other disease or illness that you may be suffering, will have to be at a level that will qualify you for benefits. If you are considering filing a long-term disability claim for drugs or alcohol addiction, then the severity of your condition must lead you to miss and remain out of work.  Some policies, however, exclude coverage for addictions relating to substance abuse.

To discuss your options about how to file a disability claim based on the condition of addiction, contact a lawyer today to understand the details of developing laws and how to use those laws to get the benefits you deserve.

What Is Surveillance in Disability Insurance?

Surveillance, or the covert monitoring of a person, is a tool used by disability insurance companies in the claims process. Disability insurers claim that surveillance is a fraud prevention tool to ensure a person’s disabilities are legitimate.

When an insurance company suspects that a person may have exaggerated or falsified his or her disability claims, surveillance might be an option to prove or disprove these suspicions.

Generally, insurance companies are permitted to surveil you in any place where you do not have a “reasonable expectation of privacy” or if you have signed an authorization to allow the insurance company to gather information about your claim.

The problem with monitoring day-to-day activities is that a surveillance report may not accurately capture a person’s limitations due to a disability. For example, on “good days” you might be able to leave your house, go grocery shopping, or have a social lunch; whereas on other days, it might be impossible to get out of bed. A surveillance investigator will be able to show pictures of your outings but will not be providing a full picture.

The feeling that your privacy is being violated is common among many who have applied for benefits. It is important to note that investigators should not trespass on private property, and you are well within your rights to contact the police or to call your lawyer.

If you would like to talk about your options under your plan or other agreements with your insurance company to limit surveillance, contact us today.

Why Do Insurance Companies Investigate Social Media?

The use of social media monitoring has been expanding in the insurance industry for purposes of surveillance. With people posting personal information on Facebook and Twitter, among many others, insurance companies are mining as much publicly shared information as possible.

Insurance claims adjusters or contract investigators might search for proof that your insurance claim is fraudulent. For example, if you were seriously injured in an automobile accident, insurance company employees might look at your recent pictures or status updates to see how the accident and the injury has affected or changed your life.

While this research might seem untoward, there are not any laws prohibiting an insurance adjuster’s ability to search social media sites for information to support their investigation into you and your claim. Most information listed on public websites is fair game, especially if you have not established privacy settings. Often times, and as more and more people use the internet to share personal information, the first step in a claims investigation is to search for the person filing a claim online and review his or her social media profiles.

Each insurance company has different policies when it comes to reviewing social media websites and each company can use your publicly-shared information in different ways. Some insurance companies have even admitted to data mining social media for purposes outside of claim investigations.

Always be cautious about what you are sharing on social media, but simultaneously, do not be afraid of sharing things that you otherwise would. If you have a question about what types of things should not be publicly-shared on social media, talk with a lawyer today.

Can I Return to Work After I Have Been Denied Long-Term Disability Benefits?

We understand that returning to work after you have been denied disability benefits is mentally and physically taxing. You might also feel that you have no other option; we want to help you understand every aspect of your denial and what might occur if you return to full-time employment.

First, returning to the workplace could negatively affect your claim. When long-term disability benefits are no longer an option, you may feel that you have to return to work.  Unfortunately, it may signify to the insurance company that you are able to work even if you are not.   There are other options before you consider a return to work so that is why it is important to speak to a lawyer.

Before deciding to return to work, it is important to holistically understand the nature of your case and whether or not an appeal or a lawsuit would be impacted by your working. If you would like more information, schedule a free consultationwith us today.

What Is a Lump Sum Settlement?

A lump sum long-term disability settlement is where an insurance company pays an amount for past and future benefits in one instance, instead of at intervals over time.

If you have been offered a lump sum disability settlement, it can be difficult to decide if you should accept the offer. The settlement amount is based on what the insurance company has calculated your claim to be worth less significant discounts for various reasons. While this calculation is intended to benefit the insurance company, it might also be in your best interest.

Once litigation is commenced, insurance companies may wish to negotiate a lump sum settlement and look at a variety of factors when making offers. For example, one of the many tools in negotiating a settlement amount is life expectancy and the severity of the disability. Long term disability insurance benefits can usually be paid until age 65, but depending on your age and health conditions, there is the unfortunate possibility that you might not survive the full period of your benefit claim.

On a more positive note, you are ending the relationship with the insurance company when you elect to receive a lump sum benefit. You are also eliminating the possibility that the insurance company could come back to you at a later date and challenge or end your benefits.

Depending on if you are negotiating a lump sum on your initial claim or on your appeal, the price differences can be dramatic. It is important to seek the advice of a lawyer skilled at negotiation and practiced at dealing with insurance companies.

How Long Will It Take to Settle My Disability Case?

Each case is different, but there are some factors that can influence how quickly your claim for long-term disability benefits will be processed by your insurance company. Specifically, the nature of your disability, the level of cooperation by your doctors, which insurance company you are working with, the success of medication and proper completion of forms.

Unfortunately, one way insurance companies avoid paying claims is to delay processing. For instance, companies might fail to return phone calls or claim they did not receive information from you. Companies might ask for additional medical evidence, even if your doctor or specialist has been entirely compliant.

Another issue that can add length to your case settlement is if your claim is denied. Many, many claims are denied upon initial review and if you choose to appeal, then the timeline of your case can stretch into months or years. These denials can lead to a cycle of legalize without benefit payments. Working with a lawyer to advocate on your behalf can help save time.   Frankly, lawsuits should be commenced almost immediately after the initial denial.   A lawsuit makes sure that a different set of eyes is reviewing your claim rather than the same adjuster who denied your claim.

In short, a disability claim can take last from a few months to a few years before you receive a decision, and even after the wait, the decision may be a denial.

After a claim denial, it is important to act quickly by gathering medical records, visiting doctors and specialists to treat your condition, and contacting a lawyer to understand how to appropriately respond to your insurance company. While filing a disability claim might be a difficult process, receiving the benefits you deserve can have a significant impact in your life.

What Is the Cost of a Disability Lawyer?

At Preszler Injury Lawyers, your initial consultation is totally free and if we can assist you, we operate on a contingency fee.  What that means is that we do not require any money upfront and should you be successful, our fees will be paid from the proceeds of the case – or the benefits we have helped the client secure.

If you do not win your case, we do not collect a fee.

Remember, it is always best to have an open and honest conversation about the help you need and what the cost of the help might be. Contact us today to discuss the facts of your case.

related videos


 

Disabilities That May Warrant Disability Claims
 

Filing a Disability Claim
 

What to do If Denied Disability Benefits
 
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