WHAT ARE LONG TERM AND SHORT TERM DISABILITY BENEFITS?
Long Term Disability (LTD) and Short Term Disability (STD) are insurance policies often included in an employee’s benefit package from an employer. These policies can also be purchased directly from an insurance company. As most issues arise with LTD claims, this will be the focus of this discussion.
WHAT BENEFITS DO LTD POLICIES PROVIDE?
If an employee becomes disabled from the job, an LTD insurance policy will pay the worker a percentage of his/her wages; this is typically 60% of the worker’s base salary. Commissions and bonuses are usually not included. Although the specific terms of an individual policy may vary, a standard policy will pay benefits for up to two years if the individual is unable to perform the material and essential duties of his/her “own” occupation; the job being performed immediately before becoming disabled from work.
If a worker is still disabled after two years, most LTD policies change the standard the worker must meet in order to qualify for additional benefits. This is typically referred to as an “any occupation” provision. The LTD insurance company is allowed to make the determination as to whether the worker is capable of performing any type of job that exists in the national economy, not just the job the person was performing when he/she became disabled. LTD insurance companies have an enormous amount of discretion in making this determination and frequently find workers capable of doing some job other than their own.
An employee who disagrees with an LTD insurance company’s assessment of his/her work capability has the right to appeal the decision. The first level of appeal is an internal review by the insurance company itself. It is imperative that this appeal be as detailed and thorough as possible. If an appeal fails at this level, the employee’s only option is to file a lawsuit against the insurance company in Federal Court. A Federal Court appeal is a very complicated, lengthy, and expensive process. Additionally, only the evidence and arguments presented to the insurance company at the internal review will be reviewed by the Federal Court.
RECENT CASES WON ON APPEAL BY ATTORNEY CLYMER
CANCER IN REMISSION
In this case the employee had been diagnosed and treated for cancer. After approximately two years of aggressive treatment, the employee was in remission. Based almost entirely on this fact the insurance company terminated his benefits.
After review of the insurance company’s decision, an appeal was filed arguing the insurer failed (1) to review all of the employee’s medical records relating to his condition; (2) did not consider all the side-effects of the medications he was required to take; (3) did not consider new symptoms the employee was experiencing as a result of his treatment and the side-effects of the treatments themselves; (4) did not conduct a fair and thorough evaluation of his limitations and how they would impact his ability to work in any occupation that exists in the national economy.
As a result of a successful appeal the employee was awarded $45,000.00 in retroactive benefits and ongoing benefits worth approximately $95,000.00 a year.
WORK INJURY COMBINED WITH LATER ACQUIRED ILLNESS
Here the employee’s initial disability was caused by a work injury which resulted in several surgeries. While recovering from her work injury the employee developed another severe condition. This condition was equally disabling and aggravated the symptoms associated with her injury at work.
On appeal, additional medical records were submitted on the employee’s behalf as the insurance company failed to obtain all of the relevant medical evidence. Therefore, an argument was successfully made that the insurer (1) relied on a medical record that was incomplete and by definition issued a decision that was unsupported by the evidence (2) failed to consider critical non-medical evidence contained in the record. This evidence pertained to an unsuccessful work attempt made by the employee despite being given accommodations by her employer; and (3) proposed alternative jobs the employee could perform that were contrary to the restrictions listed in the insurer’s denial of benefits.
A successful appeal in this case provided the employee with close to $30,000.00 of retroactive benefits and yearly benefits of approximately $50,000.00.
Insurance companies are relentless in their attempts to deny benefits to workers. In some instances a simple denial is enough to cause a person to assume it is hopeless and pointless to fight any longer. Please do not make this decision until you have consulted an attorney who is experienced in this very complicated area of the law. We strongly recommend you contact us immediately upon receipt of a denial of benefits by an insurance company as there are time limits that apply and the attorney needs ample time to review the case and in many instances obtain crucial evidence.
DON’T TAKE NO FOR AN ANSWER