Disability Insurance Claims
The Schipper Law Group provides comprehensive assistance to employees who are participants in their employer’s disability plan and independent professionals who individually purchased disability policies to provide financial security in the event of a disability. Our services can be divided into four areas: application, appeal, claims monitoring, and litigation.
Long-Term Disability Claims
If you are receiving benefits through your employer’s group benefits plan, your claim for benefits is largely controlled by the Employee Retirement Income Security Act (ERISA) and the plan’s terms and conditions of coverage. If you purchased a plan individually, your claim for benefits is controlled by state insurance and contract law as well as the plan’s terms and conditions of coverage. Unfortunately, ERISA gives insurance companies many outlets to delay or deny a valid disability insurance claim. Insurers face no real penalties for delaying and denying ERISA claims. With nothing to lose, they often use this to their advantage to unfairly avoid paying out disability benefits. In the case of ERISA-controlled plans, a large precedent of law has been churning for years that may limit your rights and remedies, including limited review of a plan’s denial, limited availability of damages and attorney fees, and no right to a jury trial. State law claims still allow for fairly expansive rights and remedies.
Application for Benefits
If at all possible, a denial of benefits should be avoided. It may otherwise take at least a year to be awarded benefits during the appeals process. The Schipper Law Group will work with you to collect your medical and vocational information and advise you on your plan’s structure, requirements, coordination with other benefits, and limitations of coverage. We will also work with you and your medical providers to present the best possible case of disability under the plan and not prejudice your claim for future benefits. Ultimately, our goal is to present comprehensive chronology to the insurer that shows your medical condition fits within their definition of disability under the plan documents and is not considered one of the plan’s increasingly large number of exclusions to coverage.
The Appeal Process
If a claim is denied — and more than half are — the appeal is the best chance for the claimant to have the matter overturned or, at the very least, set the case up for a successful lawsuit. The internal appeal process is mandatory before filing a lawsuit, and for the group plan policyholder, the evidence submitted during the appeal is largely all the evidence that will ever be considered by the insurer or by a court. A well-established precedent of law also includes that courts often must limit their review of evidence to that submitted in the administrative appeal and are often limited in their review of the evidence. Given this, it is essential to build the case during the appeal.
Insurers use all sorts of tactics to deny claims; e.g. “independent” medical reviews and exams, vocational reports by experts to which they regularly refer work, surveillance, claims of malingering, claims of non-objective evidence of pain, non-compliance with treatment, not comprehensively reviewing interaction of multiple medical conditions, and/or “cherry-picking” the records for evidence of ability to work. Thankfully, the insurer is mandated to provide the complete claim file along with an explanation regarding why it is denying benefits. It is crucial to go through the claim file looking for procedural irregularities, conflicts of interest, inaccuracies, and outright misrepresentations, and then submit contrary evidence and rationale in support of finding disability. Likewise, claimants should have their best case put forward in regard to their version of events (such as surveillance), their treating physician opinions, other expert opinions, vocational ability, and anything else that may support the finding of disability.
It is important to note that there may be a time limit of as little as 180 days to file an appeal. You should not wait to contact an attorney, and you should keep both the denial letter and the envelope in which it was mailed.
Claims Monitoring
If you have been awarded benefits (“on claim”), unfortunately, the story does not end there. There may be exclusions and limitations in your coverage that allow the insurer to end coverage at a given point in time. Likewise, the plan requires you to continue to comply with records provisions, and the plan may reopen the matter. If you fail to do so, your benefits can be limited or terminated. It is important to control the information being provided to the insurer. For example, if you have more than one condition, one of which is limited to two years of coverage (as is the case with mental impairments in most policies), it is important to place emphasis on your physical condition as the impetus for any mental disorder. Likewise, your doctors may inadvertently provide information to the insurance company or plan that may lead to the early termination of your benefits. Frequently, doctors complete disability forms quickly and without looking at the file. This may be avoided by having an experienced attorney review your medical information before it is sent off to the insurer.
Litigation
Where and under what procedure a disability matter is litigated largely depends on whether it is an employer group plan or a privately purchased plan. Privately-purchased plans are litigated in state courts and are controlled by insurance and contract laws of the state. Employer group plans are litigated in federal court and controlled by the Employee Retirement Income Security Act (ERISA). Litigating in state court is by no means easy, but any knowledgeable attorney in this area will tell you it is preferable to an ERISA matter. This is because ERISA limits the evidence considered, disallows a jury trial, may give the insurer’s view of the evidence deference and generally limits recovery to only the plan benefits that should have been awarded in the first place.
If you have been denied long-term disability benefits, have had your claim terminated, or you are just in need of consultation as to your rights and coverages, please contact The Schipper Law Group here or call us at (248) 729‑2414. Our long-term disability attorneys will explain all of your rights, explore every option, and provide you with aggressive representation when needed. We have a proven track record of achieving successful outcomes inside and outside of the courtroom.
Frequently Asked Questions
I have a legitimate disability, and my doctor says I cannot work. How can the insurer deny me?
While your insurer is supposed to consider your doctor’s opinion, they are not bound to it. The insurer in all likelihood will submit your records to an “independent” medical review or examination.
Do I have to attend an independent medical examination?
In short, yes. You are required to cooperate with the insurer’s efforts to assess your claim. It may be wise for you to bring a friend or family member to such an examination and note the process and interaction with the doctor.
I am still working, but I am finding it increasingly difficult to work. Can I file for disability now or should I quit?
The answer to this question will depend on the policy and the precise facts of each case. Most people want to continue to work, so they make adjustments to or are accommodated by their employer to continue working. At some time, however, the accommodation is no longer enough. Generally, it is not recommended that you quit work or allow yourself to be terminated before filing for benefits, as this may give the insurer a defense that your disability arose outside of your term of coverage. On the other hand, if you are working, even with an accommodation, you then give the insurer an argument that you are not disabled. Ideally, you would be on paid leave, FMLA leave, or perhaps a medical leave of absence of some kind when filing for benefits.
How long will it take to get my benefits?
It depends on your policy and the difficulty of your case. In theory, an insurer has up to 105 days to grant or deny benefits. You then have 180 days to submit an internal appeal. The insurer then has up to 120 days to make a decision on the appeal. This is over a year even before you enter the litigation phase of the matter. If a case is litigated, this could add years to the matter.
Why do I have to use the internal appeal process? Can’t we just sue them?
As a matter of law, disability plans are allowed to have an internal appeal process that participants must complete before they may litigate their claims. You are allowed no less than 180 days from the date of denial or termination to appeal the plan’s decision. Failure to submit an appeal within this timeframe may prohibit participants from further appeal or litigation and close the case. There are some exceptions to this rule, such as when an appeal can be shown to be futile or the plan has previously violated ERISA regulations. In short, the majority of appeals must utilize the plan’s appeal process in full before litigating.
Can I collect this policy and social security or workers' compensation?
This depends on whether the policy coordinates with other benefits. They usually do. What this means is that the policy deducts offsets from your monthly payment and amount(s) that you are collecting from these and some other sources of income. A majority of policies now require that you apply for social security disability benefits as a condition of coverage.
How much would it cost to retain your services? Shouldn’t the insurer pay your fee because they caused this?
There are a number of options to pay for our services including hourly, contingent, and/or a blend of each. Our goal is to set a fair fee for each case that represents the amount of work we must accomplish and still allows you to collect the lion’s share of benefits. Whether attorney’s fees are available from the opposing party depends on the facts and circumstances of the case
Long-Term Disability Appeals
As many as 65% of applicants for disability benefits are denied in the initial stage of the rigorous application process in the state of Michigan.