Long-Term Disability FAQ

The long-term disability claims process can be difficult and confusing, leaving you with more questions than answers. Visit our FAQs to get the information that you need to succeed in your claim or lawsuit.

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  • Do I Have to Submit an Administrative Appeal of My LTD Denial? Can I just sue now?

    Our office received a call recently from Janice – a very nice, 56-year-old accountant who was dealing with coronary artery disease (CAD), diabetes, and chronic degenerative disc disease.  Janice worked as an accountant at a large, chemical manufacturing facility for almost 25 years.  She had to stop working due to her medical conditions and filed a claim for long-term disability benefits through her employer’s benefit plan.  Unfortunately, she was denied because the insurer claimed she could continue doing her sedentary occupation.  She was really angry and did not want to deal with the insurance company any longer because she knew she would not get a fair shake.  Janice just wanted to sue them.  After a few minutes, Janice asked – Do I Have to Submit an Administrative Appeal of My LTD Denial?

    Do I have to submit an administrative appeal of my LTD Denial?The answer is yes if you received your LTD plan through a private sector employer.  LTD coverage provided this way likely falls under ERISA and according to ERISA, you must “exhaust” your administrative remedies before you can file a lawsuit. This means you must follow the terms of the insurance policy and go through each step of the appeals process directly with the insurance company. If the insurance policy states that you must file one appeal, then you may only need to file one mandatory appeal. If the insurance policy requires you to file two appeals, then you must go through two appeals before filing a lawsuit. Other insurance policies have one mandatory appeal and one “optional” appeal. The key is that you must review your policy to see what it requires.

    In other situations, you may not have to file an appeal at all before filing a lawsuit. This may be the case if you have an individual policy purchased directly from an insurance agent or broker, or if your policy is sponsored by a government or church employer directly.  Again, you should read your policy.

    Luckily for Janice, she made a smart choice and called Louisiana Disability Law so that we could evaluate her situation and guide her correctly (since she received her policy through a large, private sector employer her claim was guided by ERISA and she had to do the administrative appeal).  Your situation may be different and will be dependent on the specific facts and policy provisions of your policy. If in doubt, you should contact an experienced disability attorney to help guide you through the process.  Give our office a call at 985-240-9773

  • What is a Long-Term Disability Buyout? Should I Accept A Disability Buy-Out?

    A long-term disability insurance buyout is when the insurance company offers you a lump sum of money now in exchange for never having to pay you again on the policy. Should I accept a long-term disability buyout?

    If you are offered a long-term disability buyout, there are a number of things to consider.  Let’s look at an example:

    Hank is a 45-year-old surgeon who developed cancer and as a result of his treatment is left with hand tremors and other neuropsychological symptoms.  Hank purchased a long-term disability policy that paid him $20,000 per month (or $240,000 per year) until age 70 provided he remained disabled under the terms of the policy.  Since Hank is 45, the policy can remain in effect for 25 more years with a lifetime payout of $6,000,000. 

    Hank’s long-term disability insurance company has offered him a buyout. What should he consider when deciding whether to accept or reject the offer?

    Pros vs. Cons of Accepting a Long-Term Disability Buyout

    There is never an easy answer to whether to accept the buyout or not.  But, in considering the offer, you should look at the pros and cons of the situation:

    PROS

    CONS

    Finished dealing with LTD Insurer if buyout accepted

    Value received is less than the full value of the policy if you were to stay on the policy for the full term

    Do not have to look over your shoulder for LTD investigators anymore

    Lose monthly payment after acceptance of buyout

    Never worry about going to an IME or completing a new form for the LTD claim

    May have negative tax implications

    Can invest money for benefit of yourself and your family

    Don’t get to talk to your LTD case manager anymore

    If something happens to you after buyout completed (like death), LTD insurer cannot get money back

    You like dealing with the stress of a policy review and will not be able to sleep at night if this does not happen anymore

     

    Obviously, each situation is different and you should seek out the information necessary to help you make the best decision in your specific circumstances.

    Our team at Louisiana Disability Law is skilled at guiding hard-working, disabled people like you through the long-term disability process.  We can help you effectively evaluate any long-term disability buyout offer and negotiate on your behalf. 

    Give us a call today at 985-240-9773 if you received a buyout offer and don’t know where to begin! 

  • Will the Long-Term Disability Insurance Company Spy on Me?

    One of the most frequently asked questions in our long-term disability practice is “Will my long-term disability insurance company spy on me during this process?”

    More often than not, unfortunately, the answer is YES! I have piles of videos right here in my office of hard-working claimants who are fighting for disability who have been spied on by the long-term disability insurance carrier.

    Some signs to know when you may be spied on by your carrier is as follows:

    • If they send you a form asking about your activities.  The carrier may call it an activity log.  The carrier wants you to take them through your day. What do you do each day? What time do you do your activities?
    • Another question the carrier may ask you is “when is your next doctor’s appointment?” What they are looking for is information to know when you're going to be out of the house and about because people often do multiple things at one time.  For example, you may go to the grocery store, then go to the doctor’s office, and then go meet a friend – while you are out. They are looking to get you at that point in time.
    • Some other indicators of when you may be spied on by your long-term disability insurance carrier is:

    The carrier may get up to get a private investigator to follow you around to establish that you can do certain activities.

    My advice to you is pretty simple - be brutally honest with them telling them everything that you do even the minute details.

    Do not over exaggerate! For example, you don't want to say "I cannot drive" because if they find you driving they can say “oh this person is not credible.”  You don’t want to say "I do not go out of the house," because if they find you just walking to your mailbox to check your mail they prove you a liar.

    It is OK to do these things.  You do not have to prove under your disability insurance policy that you are completely inactive but if you tell the insurance company those things, it makes you out to be a liar when you are doing activities contradictory to what you told them on the activity log. 

    As long as you are brutally honest with the long-term disability insurance company, you won’t give them any ammunition to deny your claim based on your credibility.  That is one small victory that you need to take advantage of!

    I am long-term disability lawyer Loyd Bourgeois.  I want to help you fight the long-term disability insurance company who wants to take your premium but does not want to pay your claim.

    Give us a call at 985-240-9773 so we can help you fight for the benefits you paid for, earned, and deserve!

  • Do Social Security retirement benefits affect my Long-Term Disability payment?

    A recent caller to office – let’s call him Al – asked an interesting question.  Here is our exchange:

    "Al, let me see if I understand your question correctly,” I asked. 

    “You have been receiving long-term disability payments through an insurance plan and that LTD insurer reduced your benefits by the amount of your Social Security Disability.  Correct?”

    Al said, “Yes.”

    I continued, “Now that you have reached your full Social Security Retirement age, your Social Security Disability is now Social Security Retirement.  And,  you want to know if the LTD insurer can continue to offset the LTD benefit by what you now receive as Social Security Retirement. Correct?”

    Al said, “Yes.”

    “Great!” I exclaimed.  “I just like to make sure I am understanding what you are asking.”

    “Al,” I said, “Here is my lawyer answer – I don’t know.”

    I explained to Al, and now to you – how and whether any Social Security Retirement payments affect your LTD payment will be a function of the specific language of your LTD policy.  And, each policy is slightly different.  You will need to obtain a copy of your policy and read specifically what it says about receipt of any Social Security benefits.  How SS Disability and/or SS Retirement benefits are construed and/or offset are policy specific.

    In most ERISA plans that I have reviewed, the LTD policy only pays benefits until you reach your Social Security Retirement age.  If this is the case, the effect of receiving full SS Retirement benefits will be that you are now aged off of the LTD benefit. 

    In private LTD plans, the policy period varies and how each policy handles offsets for SS Retirement differ.

    So, as I told Al – “You need to get a copy of the policy and review it. And, if you don’t understand what you are reading or what you are looking for, give my office a call to schedule an appointment where we can review it together.”

    Al set off to find a copy of his policy.  If you have this question, you should do the same!

  • Am I required to provide my financial information to my Long-Term Disability Insurer?

    Well – it depends. If you are a Louisiana doctor, dentist, small-business owner, accountant, lawyer, or other professional with an individual disability policy, you may.  If you have group long-term disability coverage, your employer probably has already provided the information or minimal information may only be required.

    Am I required to give my financial information to my Long-Term Disability provider? Your policy will include specific information about what you are required to provide.  It is important for you to read your policy thoroughly if you have not already done so.  The policy will have specific provisions concerning information that you are obligated to provide. Some big issues you may run into are discussed below.

    The Financial Documents Are Complex

    If you are a business owner or medical professional with an Individually Owned Disability Policy, the disability insurance company will likely require your financial documents is going to want to go through your finances in great detail. But what will they need?  Your tax return only, or other financial statements like income statements, balance sheets, etc.?

    Simply put, your disability insurance benefits are usually based on your monthly income – so the disability insurer needs to figure that out to pay the benefits.  They will not simply take your word.  Disability Insurers often send broad requests for financial documents and tax returns for the past five years. In some cases, they may want to go back further, and some disability insurers are known for requesting financial audits in certain situations.

    Do You Have To Allow Your Financial Professionals to Speak to the Insurer?

    The disability insurer may also ask you to provide an authorization allowing them to obtain records from your accountant, bookkeeper, tax preparer, or other financial professional.  Again, depending on your policy, this may or may not be necessary.  Generally speaking, however, you are required to cooperate with the insurer’s investigation of your claim.  You may be able to limit what is requested, but that will be policy specific. 

    If you have questions about the types of financial records that your disability insurance company is entitled to receive under your policy, please call our office today at 985-240-9773.

  • Can I get punitive damages for a denied Long-Term Disability claim?

     

    Recently, while working on a claim for a disabled heavy equipment mechanic, he asked if it was possible to recover punitive damages because of his improper disability denial.  My answer to him and now you follows: 

    I know that having your disability claim denied is very frustrating. The long-term disability insurance industry has a history of bending and twisting laws just to avoid paying benefits to people who need and deserve it.  Unfortunately, the law governing Louisiana ERISA long-term disability claims simply does not have any way to hold these insurers accountable.  The ERISA law does not provide for punitive damages or bad faith damages.

    While my client was disappointed in the news, he knew there was nothing we could do. 

    However, if your plan is not an ERISA plan, you may be able to win other damages for the insurance company’s bad faith actions.  This includes those with private disability insurance policies, those employed by federal, state and local governments, and those employed by churches or other religious organizations.  Because these plans are not covered by ERISA, often they rely on state insurance laws that provide certain penalties for bad faith actions. 

    To discuss a plan of action for your denial, call disability attorney Loyd Bourgeois at 985-240-9773 for a free consultation. 

  • How does a long-term disability attorney help in my claim?

    I have spoken to many people who I simply could not help because all they did was what the disability insurance company told them to do all the way up to the time they received their final administrative denial letter.  Basically, all they have to support their claim is the minimum information the insurance company wanted.

    A good long-term disability benefits attorney will help you “stuff the administrative record” with documents and evidence helpful to your claim.  Much of it the insurance company will hate but has no choice but to accept into the record.  They hate this evidence because it makes their job much more difficult.

    How does a long-term disability attorney help your claim?Filing a successful long-term disability claim appeal includes more than just filling out forms. You must know how to use the forms and how to supplement the administrative record beyond what the insurance company asks you to provide.  To launch the best possible claim or appeal, a good disability insurance attorney will position your case for success with additional medical, vocational and financial evidence.

    This evidence is key to proving that you are disabled! And proving that the long-term disability insurance company made an arbitrary and capricious decision.

    A long-term disability attorney can help you find and acquire supporting medical and vocational records, job description evidence, plus written statements from family, co-workers and friends, and much more to support your claim. 

    In addition, depending on the case, an experienced long-term disability attorney may do any of the following:

    • Arrange for an IME (independent medical exam) or FCE (functional capacity exam) or other medical testing (CTs, MRIs, blood work) that can help confirm you are disabled and fulfill demands for “objective medical finding” stated in the insurance policy.
    • Help draft your application or appeal to argue against common misrepresentations
    • Connect your limitations to an inability to perform your job’s actual duties
    • Work closely with your physicians, medical and vocational experts to help ease any difficulties in completing their statements in the best possible light, and protect them from harassment by the insurance company.

    One reason so many long-term disability appeals are denied is because the information requested by the insurance company is vague and (in my opinion) designed to help them deny your claim. The forms and information presented to claimants by the insurance company generally make no mention of submitting specific additional evidence.

    A good, experienced long-term disability attorney can help you fight back from the beginning and stuff the administrative record with good evidence necessary to win your claim.

    8 Specific Actions To Take Before Filing Your Long-Term Disability Claim Report If you're preparing to file for long-term disability, we've created a checklist of "8 Specific Actions to Take Before Filing Your Long-Term Disability Claim."  All we need is your name and email address, and we'll send you the checklist right away.  Don't make a costly mistake before you've even applied! Just click here to receive your copy of "8 Specific Actions to Take Before Filing Your Long-Term Disability Claim."

     

  • Will new ERISA Disability regulations affect your disability claim or appeal?

    As of right now, beginning January 1, 2018, the regulations that control ERISA disability claims and appeals will change. I feel this is great news because these new regulations will provide much-needed protections to many short and long term disability claimants. 

    Will new ERISA Disability regulations affect your claim or appeal?

    These important changes to ERISA law are the result of the Department of Labor’s review of ERISA legal cases since 2000. With these new rules, DOL acknowledged that ERISA rules are inadequate from a claimant’s standpoint.

    As the Federal Register states in the Final Rule, “…[group] disability cases dominate the ERISA litigation landscape today. …Insurers and plans looking to contain disability benefit costs may be motivated to aggressively dispute disability claims. Concerns exist regarding conflicts of interest impairing the objectivity and fairness of the process for deciding claims for group health benefits.”

    Existing ERISA law and regulations make it easy for insurers to deny valid disability claims without penalties, and the legal remedies and due process for claimants are very limited.  This has resulted in many disability insurance companies handling claims in unfair and in some cases deceptive manners. 

    The new ERISA disability regulations will help level the playing field for claimants.

    The new rules will apply to both short term and long term disability benefits plans provided through your employer.

    There are seven main rule changes.  Here is a summary of each:

    Certainly, the new ERISA disability regulations come as bad news for disability insurers who do not play fair. These changes will affect their administrative costs, increase burdens of handling claims, as well as increase litigation risk and add new legal complexities that work against them rather than for them.

    1. Disability Insurance claims and appeals must be adjudicated in a manner designed to ensure independence and impartiality of the persons involved in making the benefit determination.

      This rule means there must be no conflict of interest, no unprincipled benefit denials or other breaches of fiduciary duty.

      This could result in significant changes to disability insurance offices and could provide a fertile area for litigation discovery to see if disability insurers are truly administering claims in an impartial manner.  For example, if companies promote those who deny claims over those who pay claims, the impartiality of the persons involved could be called into question.

    2. Disability Insurance denial notices must contain a complete discussion of why the plan denied the claim and the standards applied in reaching the decision, including the basis for disagreeing with the views of health care professionals, vocational professionals, or with disability benefit determinations by the Social Security Administration (SSA).

      This new regulation requires the ERISA disability insurer to tell you clearly in your denial letter why your claim was denied. If the disability insurer disagrees with SSA, this regulation seems to require them to say why.  If they disability insurer disputes your own doctor, this regulation seems to require them to set forth exactly why.  This rule seems to require the ERISA disability insurance company to list the disagreements out and explain in detail the basis for each of their findings.

    3. Claimants must be given timely notice of their right to access their entire claim file and other relevant documents and be guaranteed the right to present evidence and testimony in support of their claim during the review process.

      Did you know that you currently have right to receive your entire claim file?  Many who file claims do not even know to ask for their claim file. While the insurance company is required to provide your claim file to you, they are not required to explicitly tell you.  Under this new rule you must be notified by the insurer of your rights to access your claim file and all other insurance company documents necessary for you to properly file and develop your claim.

    4. Claimants must be given notice and a fair opportunity to respond before denials at the appeals stage are based on new or additional evidence or rationales

      With the new ERISA disability regulations, you will have the right to review and respond to new information before the Plan makes a decision on appeal. If your appeal is denied, and the denial is based on new or additional evidence, the insurer must give you fair notice and a fair chance to respond.

      Currently, it is common for the disability insurance company to receive all of your evidence and arguments disputing their decision, and then they take that evidence and have another review that essentially refutes your evidence.  You are not given another chance to dispute or refute what they have and then your claim is denied. 

      This rule seems to provide you a full and fair review by providing a right to review and respond to new evidence or rationale developed by the insurer during the administrative review prior to the appeal decision. This may be a very helpful rule.

    5. Plans cannot prohibit a claimant from seeking court review of a claim denial based on a failure to exhaust administrative remedies under the plan if the plan failed to comply with the claims procedure requirements unless the violation was the result of a minor error.

      This rule takes away the insurer’s argument that you did not get a final decision from them before going to court.  This is important because sometimes the insurance company’s strategy to deny a claim is to cause delays by withholding documents or information, or they may use other frustrating maneuvers like simply not responding to your appeal or claim. 

      The new ERISA disability regulations prevent you from being barred from suing the insurance company if you fail to complete the internal appeals process when (1) the insurance company behaves wrongly or (2) procedural errors occur. If that happens, the court reviews the disputed decision without regard for the insurer’s decision.

    6. Certain rescissions of coverage are to be treated as adverse benefit determinations triggering the plan’s appeals procedures.

      This rule amends the definition of an “adverse benefit determination” to now include a rescission (withdrawal) of disability benefit coverage that has a retroactive effect. So, a retroactive rescission of coverage is considered to be a denial of benefits that sets off the Plan’s appeal process.

    7. Required notices and disclosures issued under the claims procedure regulation must be written in a culturally and linguistically appropriate manner

      Disability denial letters must be written in a manner and language that is understandable to the claimant, or otherwise include information of the availability of language services.

    Certainly, the new ERISA disability regulations come as bad news for disability insurers who do not play fair. These changes will affect their administrative costs, increase burdens of handling claims, as well as increase litigation risk and add new legal complexities that work against them rather than for them.

    8 Specific Actions To Take Before Filing Your Long-Term Disability Claim Report If you're preparing to file for long-term disability, we've created a checklist of "8 Specific Actions to Take Before Filing Your Long-Term Disability Claim."  All we need is your name and email address, and we'll send you the checklist right away.  Don't make a costly mistake before you've even applied! Just click here to receive your copy of "8 Specific Actions to Take Before Filing Your Long-Term Disability Claim."

     

  • Do I have to attend the examination set up by the insurance company?

    In most cases, yes. However, the terms of the long-term disability policy will dictate whether or not you must comply. Most policies require that you cooperateDo I have to attend the exam set up by the insurance company? with the long-term disability insurer’s investigation and/or see their doctors. Your long-term disability benefits policy will tell you this information, which is why you need to read it carefully.

    Another question is should you attend this visit alone. In my opinion, you should not. It is not unheard of for these consulting examiners to make reports to the insurance company that are completely different from what occurred. You will be well served to have a family member or close friend travel with you to the exam and remain in the room with you the entire time. After the exam, you should write down everything that occurred and request a copy of any documents that the examiner completed. Review the documents carefully before leaving and bring any inconsistencies to the attention of the examiner immediately.

    8 Specific Actions To Take Before Filing Your Long-Term Disability Claim Report If you're preparing to file for long-term disability, we've created a checklist of "8 Specific Actions to Take Before Filing Your Long-Term Disability Claim."  All we need is your name and email address, and we'll send you the checklist right away.  Don't make a costly mistake before you've even applied! Just click here to receive your copy of "8 Specific Actions to Take Before Filing Your Long-Term Disability Claim."

  • Do I have to go through the administrative appeal?

    Yes. Under ERISA and federal law, you must exhaust your administrative remedies. That’s a fancy way of saying that you must follow the process. If you are denied by the insurance company, you have to appeal first to the insurance company again for the administrative review. If you are still denied, then you can take the matter to court.
    However, if you try to skip the administrative review and go directly to court, the court will most likely say that you failed to exhaust your administrative remedies and can dismiss your appeal.