Question 1: What is the difference between short term and long term disability?
Answer: Many disability insurance policies offer short term disability benefits, which cover the insured for a set period of time (for periods six months or less). After benefits are exhausted under the short term portion of the policy, an insured can make a claim for long term disability benefits. Long term disability benefits then can be payable usually through an insured’s 65th birthday.
Question 2: What is an elimination period?
Answer: The elimination period is a set number of days specified in the policy that an insured must wait before becoming eligible to make a claim for long term disability benefits. This time period can range anywhere from 60, 90, or 180 days, and often correlates with the same amount of time that an insured can receive short term disability benefits.
Question 3: Can I appeal the decision of the insurance company?
Answer: Yes. Disability policies allow you to appeal the decision of the administrator before you have to file suit. It is important to provide as much documentation as you can during the appeal process, because likely a court of law will only be able to review documentation that was before the plan administrator.
Question 4: What to do when my appeal is denied.
Answer: Once your appeal is denied and there are no more appeals left for the plan administrator, the next option is to file a lawsuit. Generally, you will have three years from the date of the last denial as the time period in which you must file suit.
Question 5: In what court will my suit be filed and will there be a jury trial?
Answer: If your disability insurance policy is an employee benefit, the lawsuit will be handled by a United States District Court, a federal court that has jurisdiction over ERISA cases. However, if your disability insurance policy is an individual policy, or if certain exceptions apply to ERISA, your case may end up in state court. There is no right to a jury trial in an ERISA case in federal court; the judge will make the determination. The judge’s decision will be based solely what has been provided to the plan administrator, what is called the administrative record. However, if the case is exempt from ERISA, you could be entitled to a jury trial in state court.
Question 6: What will the Court decide?
Answer: In the vast majority of decisions, the Court will determine whether, based on the administrative record, the plan administrator’s decision was reasonable or not. This standard in ERISA cases is very favorable to the insurance company. In a small number of cases, based on the policy language, the judge will be able to review all of the material and determine whether or not you are disabled, regardless of the plan administrator’s decision. This standard is much more favorable to the insured, and if possible, we will push for that standard of review to apply.
Question 7: What can I recover if the judge rules in my favor?
Answer: In ERISA cases, the amount of recovery is limited to what benefits would be payable under the contract. The judge cannot award damages for things like pain and suffering and financial hardship, which could be recovered under state law. In addition to awarding benefits under the contract the judge can, in his discretion, award attorney’s fees, costs and interest to the prevailing party.
Question 8: When should I contact an attorney?
Answer: When benefits are denied, you should contact an attorney as soon as possible to ensure that the administrative record contains all the information necessary to get your benefits reinstated. Even if you have exhausted all of your administrative appeals, you should contact an attorney as soon as possible to recover the benefits you deserve.