Most workers have Long Term Disability (LTD) insurance through a group policy where they work. People who are self-employed often have individual policies. The following cases illustrate the importance of having a legal team on your side when dealing with LTD claims.
As you read the following stories, keep in mind that LTD insurance coverage is for your entire working life (up to age 65). What if you become permanently disabled at age 37, 40 or 51? That is a lot of time to live only on Social Security Disability. LTD will supplement your SSD and enable you to have or maintain a higher standard of living. Filing a complete and timely claim with the help of an experienced legal team can make the difference in terms of your benefits and peace of mind.
(The names have been changed to protect the privacy of the individuals.)
Sheila – Age 51
A software developer by profession, Sheila was diagnosed with depression, type-1 diabetes, and tinnitus (ringing, buzzing, chirping noises in the ears). She received benefits from her LTD company from December 2009 until October 2011. Then the company denied a continuation of her claim. The denial was based on normal twenty-four month coverage for mental health disabilities (depression in Sheila’s case).
Sheila contacted an attorney about this denial. Her diabetes and tinnitus made it impossible for her to work at her career. A claim was filed based on Sheila’s physical limitations, which were ignored in the insurance company’s denial of continuation of benefits.
A sixteen-page ERISA administrative appeal and over 800 pages of medical records were sent to the insurance company on Sheila’s behalf. The insurance company agreed that Sheila couldn’t work in any occupation due to her physical condition.
Sheila will receive $5,491 a month until she turns 65.
Mark – Age 37
Mark worked as a safety trainer for a company in upstate New York.
He was diagnosed with Polymyositis (an autoimmune disease that causes weakened muscles, fatigue, sleeplessness) and rheumatoid arthritis.
His LTD company paid him for five years. Then they denied his claim!
The company told Mark that he had to see a physical therapist for a functional capacity exam (a test to determine his ability to work at his job full-time). This exam was supportive of Mark’s disability claim.
The company then put Mark under surveillance. On the day they followed and videotaped him, he was seen carrying an object from his car to his house, using a spreader to put fertilizer on his lawn, and using a rake and hose. The videotape was nine minutes long. What they did not see was that Mark went into the house and spent the rest of the day in bed. Mark can do some work around his house, but he is not capable of working eight hour days, five days a week as a safety trainer.
However, based on this nine-minute video, Mark’s claim was denied. The insurance company sent the video to the physical therapist, and the therapist changed the supportive diagnosis to unfavorable based on this short video.
Mark’s legal team filed an appeal. His policy defined long term disability as the “inability to work at any reasonable occupation based on education, training and experience.” Mark’s work history and the supporting documentation filed on Mark’s behalf showed that Mark was unable to work full-time at his profession. The insurance company agreed that the video did not prove an ability to work full-time.
Mark’s claim was reapproved.
Sean- Age 40
Sean worked as a mechanic for the Transportation Workers of America. A work accident left him disabled; he received LTD benefits of $846 starting in 1999. Sean’s insurance company did not deny that he was disabled, but in August of 2011, they offered him a lump sum of $86,000 to fully settle his claim.
Sean was entitled by his policy to receive $846/month for the next twenty-five years (until he turned 65) or a total of $253,800.
Sean needed the monthly payment to cover his bills. He could not take the lump sum and invest it hoping to earn a larger amount over time. Sean told the insurance company that he did not want the lump sum. Then in February of 2012, the company denied Sean’s claim to any further benefits!
Sean’s attorney filed an appeal challenging this decision. Sean had had three back surgeries. He was on narcotic painkillers. He had letters from physicians, and Social Security agreed that Sean was disabled and was paying him benefits.
The company’s decision was overturned on appeal. Sean does not have to worry about how he will pay his monthly bills.
Insurance companies can sometimes make things difficult for policyholders to receive covered benefits. When Sheila, Mark, and Sean needed help dealing with the insurance companies, they all received excellent results by engaging professional legal services.