Washington D.C. Long Term Disability Attorney

Claims administrators, who assess long-term disability applications, typically work for insurance companies. Despite being regulated by the Employee Retirement Income Security Act (ERISA), these administrators are directly employed by the insurance companies. These companies, responsible for paying the claims, face an inherent conflict of interest. The entity determining whether a claim should be paid is also the one obligated to make the payment.

Because of this conflict, claim processors routinely deny legitimate disability applications. These denials of long-term disability benefits happen frequently, and they are frustrating and deflating for those aiming to secure rightful benefits.

There are several reasons why your claim might be denied. In fact, if you are not careful with the wording and information in your application, you might see an automatic denial—even if the claim is legitimate.

The disability lawyers at Donahoe Kearney, PLLC can help. Our law firm can evaluate your situation, provide tailored legal advice, and assist with your long-term disability claim. Getting the right help can mean the difference between receiving benefits and losing out on life-changing payments.

3 Truths About Long-Term Disability Insurance In DC

1. The Disability Claim Process Will Vary Depending on What Type of Claim You’re Making.

There are different types of disability claims, including:

• Short-term disability insurance claims
• Long-term disability claims
• Social Security Disability claims
• ERISA
• Non-ERISA
• Family and Medical Leave Act (FMLA) FMLA claims

Each type of claim will have its own timeline and rules that govern the process. It’s important to understand or have someone on your side who understands the process for the specific type of claim you are making and can help you stand up to the insurance company.

Some processes can move quickly, while others take more time. After a serious injury or medical condition prevents you from working, it’s crucial to determine the best way to replace the income you are losing. If you work for a private company and have a long-term disability policy provided by your employer or have purchased your own individual policy, you will need a disability lawyer familiar with ERISA law to help you take the next right steps.

2. The Long-Term Disability Claim Process Involves an Administrative Record & Important Timelines.

Are you making a long-term disability insurance claim? If so, there may come a time when your claim is either denied or your benefits terminate, and you will be required to appeal that denial.

That appeal goes to the insurance company (I know it sounds crazy, but the insurance company will decide whether to stick with or change their denial of your benefits). Everything you submit during the appeal process will be part of the administrative record. The record covers the time period from when you were injured through your current condition. It is critical that this administrative record is delivered on time and contains all the critical information to support your claim.

This is not filling out some forms or just sending in your medical records — there is an entire process you should go through involving medical and vocational evidence that you and your disability attorney will prepare. Our appeals average over 20 pages (single-spaced) plus another 75 – 100 pages of exhibits and evidence that we created to support the appeal.

There is also a timeline of events that you must follow exactly, or you risk having your claim denied. ERISA long-term disability insurance deadlines include 180 days after any claim denial for an administrative appeal, and the insurance company has a 45-day deadline to review an appeal once submitted. That’s not a lot of time to get your administrative record together, especially if you don’t know exactly what you need.

3. Hiring Our Experienced Long-Term Disability Lawyers Will Make the Entire Process Smoother.

If you have questions about ERISA long-term disability cases, contact our experienced legal team to get more information on the process. Getting help is especially important if the insurance company denies your claim. Donahoe Kearney, PLLC can review your denial letter as part of their case evaluation and free consultation process.

What is the Difference Between Workers’ Compensation and Long-Term Disability?

The biggest difference between workers’ compensation benefits and long-term disability (LTD) benefits is that workers’ compensation is exclusively for an injury related to work. LTD benefits, on the other hand, can apply no matter how you were injured or how your health condition occurred.

Workers’ compensation also involves a fixed amount of benefits based on the type of injury and how much you earned prior to the work injury or accident. Workers’ compensation benefits will also pay for medical care and related follow-up for your injury as well. Once you are well enough to go back to work, benefits will often stop. Benefits are also capped based on the body part affected and how severe your work injury might be. Each state has its own workers’ compensation laws.

In contrast, ERISA governs most long-term disability benefits insurance policies. It has strict deadlines, restrictions on benefits, and complicated requirements. While workers’ compensation is extremely worker-friendly, LTD benefits do not have that type of mentality.

However, you can get LTD benefits for any type of injury or illness (even a personal injury from a car accident or slip and fall), regardless of whether it occurred at work. As a result, the benefits might be broader compared to workers’ compensation. LTD benefits also do not offer medical care; you typically receive monthly payments for the time you are disabled or for a specific time frame as set out by your policy.

How Do DC Workers Qualify for Long-Term Disability?

Qualifying for long-term disability benefits can be complicated. Requirements to qualify will depend on what kind of long-term disability policy you have. The main distinction is between private insurance policies and ERISA disability benefits.

Private Disability Insurance

Long-term disability policies can be confusing. You must be able to read between the lines and sort through a whole bunch of industry-specific terms and conditions.

Private disability insurance replaces all or some of your income if you become disabled and cannot work. You can purchase private disability insurance on your own, or it might be offered through your place of employment.

Qualifying for private disability insurance starts with filing a claim with your insurance company. That claim should include evidence of your disabling condition, such as medical records and treatment notes.

Every policy is slightly different, but most policies will require that you fall into one of the two categories.

• Any-occupation. You can only receive benefits if you cannot work any job, regardless of whether the job is in your prior field or occupation.
• Own-occupation. You can receive benefits if you can no longer work in the occupation you were in before your injury or illness. However, you might be able to work in another field or occupation.

There are also several types of private insurance that get into much more specific qualifications regarding your occupation. These distinctions can be difficult to understand, and they are very precise. Having a disability attorney to help you navigate these terms and requirements can be very beneficial.

ERISA Disability Benefits

ERISA governs disability insurance benefits offered by an employer as part of an employee benefits package. It does not apply to private insurance plans that workers can buy without involving their employer.

The benefits from ERISA plans are similar, but there are some additional requirements that you may need to meet. Perhaps the most important qualification deals with the timing to file a claim. You have short deadlines, and working through the appeal process if your claim is denied can be time-consuming and complicated.

Reasons Why Your Disability Claim Might Be Denied in Washington, DC

Receiving a denial from an LTD application happens frequently, but it often occurs for one or more of the same reasons. The most common reasons a claim is denied are included below.

Failure to Meet the Definition of Disability

To qualify for LTD benefits, you must meet the definition of disabled. The definition of disability varies based on the type of policy you have. For instance, the definition of disabled will be broader in an “own-occupation” policy than an “any occupation” policy.

• Own occupation: You are medically unable to carry out the duties of your specific occupation.
• Any occupation: You cannot perform the duties of any job.

There might also be specific time frames that you have to meet the definition of disabled before you qualify, such as several months or even years. Some policies also change from own occupation to any occupation after a specific length of time, usually a few years.

Insufficient Evidence

The information you provide in your disability application is the only information that a claims administrator may consider at the outset of evaluating your claim. If you do not provide enough information, this is an easy way to deny your claim.

In general, you should have complete medical records available that show a history of regular medical treatment. If you do not keep up with medical care, an administrator might see that as evidence that you do not believe your condition is severe or actually inhibits your ability to work. Having a doctor’s statement about your condition to go along with your application might be helpful as well.

Missed Deadlines

Long-term disability insurance policy deadlines can be short and hard to decipher. Keep in mind that you have deadlines that apply to both filing your initial claim and appealing any denial of that claim. If your initial claim is denied, most policies allow for 180 days to appeal. This time will go by quickly, so involve a disability attorney sooner than later in the appeal process.

What Should I Do If I Am Denied Long-Term Disability?

Reread Policy Documents

Be sure to have a copy of your policy on hand. These terms and conditions are important, and you should know and understand them. If your claim was denied, rereading the policy is the best place to determine whether the denial was appropriate.

If you do not have a copy of the policy, ask your company’s human resource manager or whoever deals with benefits for your employer. If you have trouble getting these documents from your employer, make a written request to the plan administrator at the insurance company. They must provide you with the plan by federal law once you make this written request.

Gather Medical Evidence

Claims administrators often deny claims because of a lack of medical evidence. As a rule, err on the side of over-providing instead of only providing a sample of some of your records. You want to show a consistent pattern of the medical condition as well as regular follow-up care.

If your claim is denied, you may need to gather additional records. If you are missing any records, track those down so you can include them with your appeal. You might also want to consider undergoing additional tests and treatment. In some cases, hiring a medical expert or meeting with your doctor to get a specific letter from your treating physician addressing your medical condition and how it fits within the insurance company’s definition of “disabled” might be the best way to present your case.

Hire an Attorney

Having an attorney on your side during the appeal process can be extremely helpful. Disability insurance lawyers know the process and the best ways to meet policy requirements, increasing your chances of disability claim approval.

You should consult with a DC long-term disability attorney before crafting your long-term disability appeal for the following reasons:

• You need someone who understands the policy terms, conditions and language to clarify the process and the parameters.
• You need someone with experience in insurance litigation to craft the appeal, to work with experts, consultants, your doctors, and witnesses.
• You also need someone who will understand how to prepare your appeal to be read by a federal judge (you have to file a federal lawsuit if your appeal is denied) so you have a fighting chance to win your appeal.

Your attorney can accomplish all of these things and more — they will be a knowledgeable companion through this difficult process.

How Much Does Long-Term Disability Attorneys Cost?

We offer consultations, claim appeals, and federal court appeals. An experienced Donahoe Kearney, PLLC attorney will review your denial letter for free and provide clear guidance on your recommended next steps.

Do Not Lose Out on Long-Term Disability

Our experienced Washington DC long-term disability attorneys are here to help! We will review your denial letter as part of our case evaluation process and free consultation process and give you our sense of the next steps you’ll need to take. But do not delay — these cases have strict time limits, and a proper appeal — one that puts you in the best position to get disability benefits awarded — requires several hours of work. Contact us today and send your denial letter to us at info@dkllp.com

To learn more about your long-term disability claim, download our free copy of “The Ugly Truth About Disability Insurance.”

For additional resources, you can read one of our 12 published books written by our nationally recognized, board-certified trial lawyers. We have served Washington DC workers for over 27 years and pride ourselves on our ability to eliminate stress and anxiety for our clients. Give us a call now at (202) 393-3320 to review your denial letter.