Insurance Long-Term Disability Claims

Oftentimes, people have short-term disability insurance benefits and/or long-term disability insurance benefits through their work.  Most of the benefit plans are far under the federal law called ERISA (Employee Retirement Income Security Act of 1974).  This law governs how these plans work and what remedies and procedures both the insurance company and the claimant must follow.

Most ERISA-based LTD policies provide disability benefits at a certain percentage (typically 50% or 60%) of what you were last earning.  And most of these policies will provide benefits for the first 24 months of disability if you cannot perform the job you were doing.  This is called the "own occupation" period.  After 24 months of disability, the standard usually changes to whether you can perform any job for which you are qualified to perform.  This is called the "any occupation" standard.  Oftentimes, the insurance company will try to terminate your benefits at the 24-month mark due to this change from "own occupation" to "any occupation" standard.

If your claim is terminated, you are entitled under the ERISA framework to appeal your case to the insurance company and ask them to reverse their decision.  This is called the "administrative appeal."  This is your last chance to add medical records and supporting expert statements to your claim file, because after the insurance company makes its decision on your administrative appeal, you most likely will not be able to add any additional records after that point.

If the insurance company denies your administrative appeal, your only option is to file a lawsuit in Federal Court.  There, the judge will review what was in your claim file and determine whether the insurance company's denial was proper.