Mydisabilityappeal.com is about resolving your disability appeal with a private insurer. While we no longer handle social security or workers compensation disability claims, we know how those claims may impact your long term disability appeal. We also know how insurance companies delay, deny and defend long term disability claims to manipulate the appeals process for their own gain.
What does “disability” really mean?
“Disability” is a term of art with specific meaning for purposes of your disability claim. LTD policies sometimes require “objective” evidence (testing not dependent on your complaints) demonstrating inability to perform “material duties” of your “own occupation”.
Consider this common scenario when gathering evidence to overturn your denied claim for Long Term Disability benefits.
“You know you can’t perform your job. Your doctor agrees with you. So, when the Long Term Disability insurer denies based on the opinion of its own “expert”, you do what any reasonable person would do: you ask your treating doctor for an opinion. Your doctor is no fan of insurers and he agrees. You pat yourself on the back… but not so fast.”
The key here is that the medical opinions supporting your case must track the policy’s specific applicable “disability” definition. An opinion from your doctor simply stating you are disabled is frequently insufficient to overturn an LTD denial.
To get the best evidence to overturn a denial, Richard Rizk first examines your policy and plan compared to your specific job description. He then writes treating physicians queries tailored to and tracking applicable policy terms.
Most doctors want to help their patients, but they simply do not know how to properly phrase letters to support your claim. Also, keep in mind that physicians are busy and responding to these inquiries often takes a lot of time.
Unethical tactics used by insurers to Delay, Deny and Defend long term disability claims can severely affect the appeals process and hurt your chances of reversing a denied claim. The following information explains a few instances where insurers may use a wide assortment of tactics not limited to stalling.
Time Is Not On Your Side
Unfortunately, time is not on your side – your window for appealing your LTD denial is limited. LTD insurers know this and have been known to use stalling tactics to shorten your window for appealing. Some of these tactics may include:
- Interpreting the meaning of the word “disability” inconsistently in order to cause confusion and delay;
- Sending incorrect forms to the claimant through the mail; or
- Claiming that returned forms have been misplaced or not received.
The Slippery Self-insured
Some big name employers self-insure their long term disability insurance. In other words, rather than buy an insurance policy, these employers are so powerful, they simply pay long term disability claims themselves. Since such employers are not in the business of insurance, they contract out processing of the long term disability claim to an “administrator “insurance company who deals directly with the claimant and the claim.
Often the big name employer will claim “we have nothing to do with your disability claim, the insurance company handles that”. Then an H.R rep for the self- insured employer attempts meet directly with the disabled employee under the guise of offering a “severance” agreement. After all, they argue, an employer has a right to meet with its own employee.
The problem: self-insured employers wear two hats: 1. Employer; and 2. Disability insurer. In the course of negotiating a so called severance agreement many self- insured employers sneak in a term stating that the employee waives any right under ERISA. Of course, the employee signs not knowing what ERISA is or that he or she just signed away rights to disability benefits. NEVER SIGN A SEVERANCE AGREEMENT WITHOUT LEGAL REPRESENTATION.
The Claim Less Examined
During the 1990s one major long term disability insurer had an epiphany! Why pay claims examiners to consider long term disability claims in the “any occupation” period when few will ever be able to prove disability from any occupation? Let’s just deny all any occupation claims and just make disabled claimants prove we are wrong. How can we lose, the insurer reasoned, ERISA the federal law governing employer provided long term disability does not provide for a bad faith claim against disability insurers like us. Besides, the disabled person is probably too ill to fight us.
That insurer was sued by several state attorney generals and eventually paid a large settlement. But, old habits die hard. Contact a long term disability attorney and your state attorney general in writing if you fear your LTD carrier has not examined your any occupation long term disability claim.
ERISA Disability Claims: Fox guarding the hen-house?
If your employer provided you with a Long Term Disability plan and policy, chances are the LTD plan grants the LTD insurer “discretion to determine benefits.” To find out whether you are subject to this term, request a copy of your LTD “plan” and “policy”. Then, look for “discretionary clause”. Such a clause will allow the insurer discretion to determine benefits.
If your policy and plan contain such a clause, your LTD insurer has great power to determine whether you should be entitled to benefits. And, should you disagree with the decision of the LTD insurer, you will probably be required to prove that the insurer “abused” its discretion in evaluating your claim. So, if a discretionary clause exists, you need to show that the insurer was unreasonable in denial and claim evaluation. In other words, and as illogical as it sounds, proof of disability may not be enough to overturn a Long Term Disability denial where the policy gives the insurer discretion in claim evaluation. Since insurers almost always hire a so-called “independent” exam or review by their own doctors, the insurer — in most cases — will have some evidence to show that its decision was reasonable.
According to the 9th Circuit Court of Appeals, deference to the administrator applies “even if it is possible to draw two inconsistent conclusions from the evidence” (see Maynard v. City of San Jose, 37 F3d 1396 ). In another case, the 9th Circuit Court of Appealsexplained that, when a discretionary clause is present, a reviewing court must defer to the insurer’s findings when there is “any reasonable basis” to support its decision regarding LTD benefits (see Horan v. Kaiser Steel Retirement Plan 947 F2d 1412 ).
One method Richard Rizk employs to overturn such denials is to attack the denial language rather than the medical opinions that support it. For example, if a denial claims that no objective findings support a disability — but neither the policy nor plan require objective findings (x-rays, for example) — then I may argue that the insurer had “abused discretion” by not applying the correct legal standard.
However, there are time limits for appealing LTD insurers’ decisions. If you have a denied LTD claim, fill out the evaluation form contact an attorney well-versed in overturning LTD denial right away. If you do not have a claim, contact your Human Resources representative and, in writing, request that your employer change to an LTD plan that does not give the insurer rights to guard its own hen-house.
Depression Power Play: LTD insurers capitalize on depression to limit LTD claims
You have a disabling condition. The disabling condition is serious and you are understandably concerned. Meanwhile, your Long Term Disability insurer hounds you and your doctors for “information”. You are afraid and even depressed. All this is just too much. So, you tell your doctor you are depressed and she diagnoses depression or some other psychiatric disorder.
Your psychiatric difficulties — coupled with your primary disabling condition — have drastically increased your inability to work. You reasonably deduce that proving disability should be no problem in light of your worsened condition.
You could be wrong.
Long Term Disability insurers often capitalize on depression and other psychiatric diagnoses to limit their exposure. Suppose you have multiple sclerosis and file a disability claim based on that. However, you later become depressed. The insurer might respond by processing your disability as depression rather than multiple sclerosis because Long Term Disability policies frequently provide very limited benefits for psychiatric conditions such as depression, anxiety and addiction/substance abuse. By contrast, LTD policies often provide better benefits for physically disabling conditions.
Richard Rizk knows how disability insurers think because he has worked for three: Wausau Insurance, Saif Corporation, and Nationwide Insurance. He also knows that psychiatric conditions are often consequences of primary disabling conditions. If that is true with your case, Mr. Rizk will help secure the medical evidence you need to prove your disability by carefully crafting questions to medical providers in light of specific policy requirements and definitions.
News and Information
The following sources provide news and information about disability insurance and the companies that provide that coverage.
“Filing a Claim for Your Health or Disability Benefits”
“Discretionary clauses gone wild: National Association of Insurance Commissioners rails Standard Insurance’s in Amicus Brief”
60 Minutes on Unum
Mutual of Omaha Attachment: doebr.pdf
“Amicus Brief of the United States against Mutual of Omaha relating to AIDS as a disability”
Disability Insurance Providers
Below are links to a few of the many disability insurance companies who provide long term disability insurance:
The Standard, Unum, Aetna Insurance, Metropolitan Life Insurance Company (Metlife),Regence Life and Health Insurance Company, Massachusetts Mutual, Mutual of Omaha,Country Insurance, Northwestern Mutual, Colonial Life Insurance Company, AXA Insurance,Berkshire Insurance, CNA Insurance, Cigna Insurance, Equitable Insurance, Guardian Insurance, Prudential Insurance, New York Life Insurance, John Hancock Insurance Company