Understanding Short and Long Term Disability Claims and Appeals

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By: Bill Henry
PublishedAug 20, 2018
4 minute read

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Short and Long Term Disability Overview

According to Forbes, 90 percent of disability claims are due to illnesses or injuries sustained while not on the job. This is when private disability insurance comes in handy. Unlike workers’ compensation insurance, most private disability insurance plans cover injuries and illnesses whether they happen on the job or not.

Schedule a case assessment with a Disability Lawyer by calling (303) 688-0944, or schedule online now.

Despite how one may feel about disability insurance, the reality is that 1 worker in 4 will become disabled before they reach retirement age. So, of the 25 percent of workers who become disabled, 9 workers out of 10 will need disability insurance due to workers’ compensation not covering off-the-job injuries and illnesses. And despite the clear need for disability insurance, 66 percent of workers will find that they are on their own when it comes to selecting and paying for a policy because their employer doesn’t offer it as an employee benefit.

So where does one start with looking for a plan? Or what does an injured worker need to know when submitting a claim? And what options are there for those who run into a claim being denied? These questions are very common for those seeking, or who already have disability insurance. While there is no blanket answer, as all policies are unique to each worker’s needs and current health, there are general guidelines that one may follow.

To learn more, please reference our legal guide “Must-Knows about Disability Insurance” and learn how to find the right disability insurance, submit a claim, increase your chances for a successful claim and learn about the appeal process. 

Common Issues Workers Encounter with Disability Insurance

Excluded Conditions

There are different circumstances when a medical condition will not be covered by an insurance company.

  • Conditions that can never be eligible for coverage: drug abuse, alcoholism, and disabilities that arise due to attempted suicide and/or criminal activity.
  • Pre-existing conditions:any disabilities that arise from a medical episode that occurred in the last 30 days or 90 days (depending on the policy) before coverage.
  • Conditions that only receive temporary benefits:mental, neuromusculoskeletal or soft tissue disorders are sometimes only eligible to receive benefits for 24 months, after which a policy will discontinue issuing payments.

Shopping for Insurance

When looking for a disability insurance policy, many workers may find that health factors and excluded conditions make finding a disability insurance policy quite difficult. Physical factors such as gender, age and occupation can drive up premium costs. Additionally, those who have suffered a “medical episode” in the last 30 days may find themselves unable to get disability insurance due to provisions on excluded conditions and “look-back period” reviews.

In addition to eligibility questions, workers may also find themselves asking, “How much disability insurance do I need?” Simply put, a worker must first figure out what the financial requirements are for covering their basic financial needs. Adding together important bills such as mortgage (or rent), car payments, loan payments (so as not to default), food and other needed expenses, is important in figuring out what income is needed to sustain yourself should you become unable to work.

Submitting a Claim for Disability

Should a worker have the unfortunate need to submit a claim due to a disability, there can be a lot of stress figuring out the process, abiding by deadlines and making sure all required evidence is submitted for a successful outcome. Arguably the best defense against this anxiety-ridden process is knowledge.

Before diving into the application process, it’s important to know that evidence is key when making a claim. There must be multiple types of evidence, and most importantly an applicant must make subjective evidence credible. When compiling evidence, it’s important to know that there are two forms of medical evidence: subjective and objective. Objective evidence (like x-rays and blood tests) must back up subjective evidence (claims of pain and fatigue) to make them more credible.

A disabled worker may also wish to utilize expert witnesses to lend credibility to their case. Remember, a statement from your physician is not enough proof for an insurance company; they will want physical evidence of your disability, which shows to what extent the disability incapacitates your ability to perform your job duties. Vocational experts and functional capacity evaluations are some of the tools that are useful for building a strong claim.

As for abiding by deadlines, each insurance company has its own rules surrounding when a claim must be filed, but typically most insurers require a claimant to file within 30 days of becoming unable to work. After your claim is submitted, pay attention to any forms or files you receive from your insurer for action dates.

Appealing a Denial

Should a worker find their claim denied by their insurance, there are two important things to know: most policies give workers 180 days to submit an appeal and the evidence that is submitted with the appeal is usually the only evidence that can be used during litigation. Thus, it’s extremely important that all the evidence your case may need be researched and obtained during this six month period.

When appealing a denial, there are a few additional things to keep in mind:

  • Use the original denial letter to start building your case.
  • Contact the insurer and request your complete file.
  • Submit all the evidence you might need should your case go to litigation.
  • Abide by your insurer’s deadlines.

Even better is that, contrary to popular belief, a disability attorney is an affordable option. Law dictates certain ethical standards for attorneys, one being that they must operate in their client’s best interest. Hence, we will work with you to determine the best fee arrangement for you. Depending on the strength of your case, Robinson & Henry offers either an hourly fee agreement or a contingent fee agreement. According to the American Bar Association, a contingent fee agreement is one in which the client doesn’t pay any fees if the case is lost; if the case is won, then the fee – usually a fixed percentage – will be taken out of the amount won.

Contact Us for Help

Having to deal with the pain, anxiety, and uncertainty surrounding a disability is enough stress for a disabled worker. The good news is that you don’t have to go it alone. A disability lawyer knows what kind of evidence an insurance company needs to approve a claim. A good lawyer is trained to review the details of your policy and to work with your medical professionals to build the best case for your claim and/or appeal.

If you’d like to schedule your case assessment with our disability attorney, call (303) 688-0944.  

To learn more, please reference our legal guide “Must-Knows about Disability Insurance” and learn how to find the right disability insurance, submit a claim, increase your chances for a successful claim and learn about the appeal process. 

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