ARE YOUR STD OR LTD BENEFITS IN JEOPARDY?

• Have you received a letter from your disability insurance company denying your claim?
• Have you received a letter from your disability insurance company ending your disability benefits?
• Have you received a letter from your disability insurance company threatening to deny your claim or to end your disability benefits?
• Has a representative from your disability insurance company said something worrisome to you over the phone?

If you answered “Yes” to any of these questions, your short term disability (STD) or long term disability (LTD) claim may be in jeopardy.

STD and LTD benefits are usually offered by your employer as a part of your benefits options. These benefits are different from what the Social Security Administration (SSA) provides through the SSDI disability insurance program or the SSI disability program.

If you have applied for or received benefits from the following insurance companies, this article may apply to you:

• Aetna Life
• Assurant
• Cigna (LINA)
• Disability Management Services
• Disability Reinsurance Management Services
• Guardian
• Hartford
• Liberty Life
• Lincoln Life
• MetLife Prudential
• Principal
• Prudential
• Reliance
• Sedgwick
• Standard
• Sun Life Mutual (United) of Omaha
• Unum

What Can I Do?

First, if you have received a letter from your insurance company denying your claim or ending your benefits, it is critical that you fully read the insurer’s letter. If the insurer made mistakes in the letter or left things out of the letter, make note of those.

It is also essential that you review the date of the letter itself, as well as the amount of time that you have to appeal the decision. These two dates will usually tell you when your appeal would be due.

Consider your recent medical appointments and whether your insurer has all the relevant evidence. It is likely that they do not. Also consider whether your physicians responded to any forms that your insurer sent to them.

How Much Time Do I Have for an Appeal?

Most STD and LTD benefits are governed by the Employee Retirement Income Security (ERISA). It is a federal benefits law. ERISA requires disability insurers to abide by certain rules and regulations. One of the most common rules is that the disability insurer allow you 180 days to submit your STD or LTD appeal. This 180 day ERISA period begins on the date of the insurer’s denial letter (or sometimes on the date you receive it).

However, it is possible that you have fewer than 180 days to submit your STD or LTD appeal. Again, please review the insurer’s letter carefully. If you are unsure, contact an attorney. Our office regularly appeals STD and LTD claims.

Missing your appeal deadline will prevent you from later appealing the decision. It will also prevent you from later bringing a lawsuit against the insurer. These deadlines are not forgiving. If an appeal deadline has expired, it is nearly impossible to keep a claim alive.

What Is an Appeal, and What Goes Into It?

An appeal with the insurer is the opportunity to have benefits awarded (either for the first time or their reinstatement after they end). The insurer’s letter should tell you what they require to award benefits. However, there are often other kinds of information, documents, and evidence that will also help in an appeal. The insurer’s letter will not address each possible individual source of helpful evidence.

Each claim will require somewhat different types and degrees of evidence. However, as a general rule, medical records; treatment notes or progress notes; medical opinion letters; medical assessments; medical evaluations; functional capacity evaluations (FCE); neuropsychological evaluations; and some kinds of non-medical evidence.

Your STD or LTD claim file with the insurer is also an essential part of preparing an appeal. A claim file will contain the insurer’s internal correspondence; correspondence with you; correspondence with your employer; medical records and opinions; application documents; and other documents. The claim file will show the way that the insurer came to the decision to deny or terminate STD or LTD benefits.

The STD or LTD policy and plan documents are also necessary to prepare an appeal. These usually look and read like contracts. They are legally enforceable agreements that govern STD and LTD benefits decisions. Some insurers include a copy of the policy with the claim file. Although this isn’t the most interesting reading, it is the only way of knowing what rights you have and what responsibilities your STD or LTD insurer has.

What If the Insurer Won’t Accept an Appeal?

Some decisions are final. This is common when the insurer has issued a denial or termination letter in the past. In this situation, a lawsuit against the insurer may be the only remaining way to go forward.

Again, the dates are important. There also strict deadlines that apply in filing a lawsuit. Every day counts, and it is important to act or seek legal counsel quickly. It is also important to review your disability policy to determine the statute of limitations for filing a lawsuit.

What if I Haven’t Received a Denial Letter?

If you have not received a denial letter, it is possible that your STD or LTD benefits are still in jeopardy. This depends on how your disability insurer is handling your claim.

If you have received letters from the insurer asking for additional information or documents, your STD or LTD claim is likely under review. These reviews are normal, but they also are where the insurer denies or ends disability benefits. If the insurer’s letters give you specific deadlines to submit records for their review, understand that your claim may be in jeopardy.

Similarly, if you aren’t comfortable with the way that a conversation with your claims representative went, your claim might be in jeopardy. Again, these are only general statements and suggestions, though. The specifics of each claim are crucial.

If you are concerned with the status of your STD or LTD claim, we would be happy to speak with you. We regularly handle STD and LTD applications, appeals, and lawsuits with many disability insurance companies. Please contact our office to schedule a consultation.