Whether you have disability insurance coverage through your employer or independently through your own personalized insurance coverage, you are entitled to receive disability benefits if you have a qualifying condition. Insurance policies can vary considerably. A disability insurance lawyer can assess your plan and the language of the contract and determine the obligations that apply to you, the claimant, and those that apply to the insurer. Understanding the provisions and language of your disability insurance policy and how it will be enforced is critical.
In some cases, insurers try to impose restrictive provisions to impede a claimant’s ability to receive disability benefits. For example, a carrier may require a claimant to attend a medical examination at a facility located hours away from their home. Failure to attend this examination can be deemed a failure to cooperate under the insurance policy.
If you are suffering from a disabling condition and are no longer able to work, disability benefits can provide the lifeline you need to support yourself and your family. Whether your disability is short or long-term in nature, a denial or termination of benefits can be devastating. To ensure your right to compensation is protected, it is crucial you have a skilled Houston disability insurance lawyer on your side.
Insurance Company Duty of Good Faith and Fair Dealing
If an insurance company denies a claim for disability benefits and the administrative appeal does not succeed, then you may be entitled to sue them for wrongful denial and for violating the duty of good faith and fair dealing that is implied in the insurance contract. The duty of good faith is important given that insurers are in a position where they have superior bargaining power and resources.
An insurer may be found to have violated its duty of good faith by engaging in the following bad faith conduct:
- Denying benefits without proper justification
- Unreasonably delaying or otherwise withholding payment of benefits
- Violating obligations imposed on them by contract
- Terminating existing disability benefits prematurely
- Intimidating or otherwise coercing the claimant
Qualifying For Disability Benefits
Applying for and receiving disability benefits can be a procedurally, substantively, and emotionally challenging process. Although one might expect an insurance company to pay when a claimant has a legitimate disability entitling them to benefits they’ve paid for, insurers often deny disability claims and frequently employ bad faith tactics that are intended to frustrate the efforts of the disabled claimant.
In order for a claimant to be eligible to receive disability benefits, they must show that their disability satisfies the requirements outlined by the insurance plan. What constitutes a “disability” can vary significantly from plan to plan. In some cases, a disability insurance policy gives provides only a general definition of disability, thus creating an opportunity for the insurer to restrictively interpret the definition. In other cases, the policy provides a general definition along with specific examples of covered disabilities — presumptive disabilities — that by default qualify a claimant for benefits under the contract.
Your disability insurance policy’s definition of disability determines whether or not you qualify to receive benefits. Some of the factors that comprise various disability definitions include but are not limited to:
- Whether the condition restricts you from working at your current job
- Whether the condition restricts you from working at any job
- Whether the disability is partial or total
- Whether the disability is long-term/permanent or short-term/temporary
- Whether you are receiving disability income from other sources (e.g., social security disability)
The language in your disability insurance contract may be quite technical, so it’s important that you consult with an experienced disability insurance lawyer who is capable of assessing the terms of your insurance plan and determining whether your condition is likely to qualify for benefits.
Appealing a denial of a disability benefits claim is often the last opportunity you will have to introduce a comprehensive record relating to your disability (e.g., medical records, wage loss documentation, etc.). This administrative record will be assessed during civil litigation if the appeal fails. It’s critical that you work with an attorney who is experienced in the disability benefit appeals process and who can assist you in gathering the necessary documentation to ensure your administrative record is comprehensive.
Types of Disability Insurance Claims
Long Term Disability Insurance Claims
Some illnesses and injuries can prevent you from returning to work for several months or even years. In these situations, long-term disability insurance is designed to replace a portion of your income when you are unable to work for an extended period.
Unfortunately, the insurance companies who issue disability insurance policies often make it very difficult to collect the benefits you have paid for. If you have been denied long-term disability coverage or your benefits have been terminated, a disability insurance lawyer can help you get the financial support you need to make it through a very difficult time in your life.
If you have submitted a long-term disability claim and your insurer has denied it, delayed processing it, or significantly undervalued it, you may be entitled to appeal the carrier’s decision and, if needed, litigate against your insurer for wrongful denial. A long-term disability lawyer can help you with your claim, appeal, and lawsuit, and will fight to recover your rightful benefits due and other compensation as allowed by law.
While short-term disability benefits may expire after six months, long-term disability benefits often last until retirement age or until you have sufficiently recovered such that you are capable of returning to work. The assumption of long-term disability coverage is that the long-term disability at issue will not necessarily be fully resolved.
For example, if you suffer an accident in Houston or elsewhere that renders you a paraplegic, you may qualify for long-term disability insurance coverage. This coverage is not intended to be a “stopgap” measure, as your disability will not resolve itself after some length of time has passed.
Critically, however, insurers will attempt to lower their payouts by arguing that your health condition is such that you are only partially disabled, not fully disabled. If you are capable of working a lower-paying job, the insurer will assert that you should take an alternative position so they can pay less benefits or no benefits. With the aid of a skilled Houston disability insurance lawyer, however, you can demonstrate that the jobs you can handle pay significantly less than your pre-disability income, such that you are still qualified to receive full long term disability benefits.
Short Term Disability Insurance Claims
Short term disability benefits are temporary and are intended to provide replacement income to tide you over until you are no longer disabled. Unfortunately, despite the fact that many disabilities (including short term disabilities) are quite serious, insurance companies routinely deny and delay claims, terminate existing benefits, and otherwise impede a claimant’s ability to receive full and adequate benefits. An experienced Houston disability insurance lawyer can help you fight for the benefits you deserve.
In Texas, as in other states, insurance providers are required to act in good faith when handling disability insurance claims. If an insurer has acted in bad faith in denying a disability claim — in other words, if it acted improperly or unreasonably — then you may be entitled to sue and recover damages.
Bad faith or wrongful conduct by an insurer includes, but is not necessarily limited, to:
- Delaying payment of benefits
- Denying benefits when the evidence clearly justifies payment
- Intimidating or otherwise coercing the claimant
- Terminating benefits and/or coverage prematurely
Depending on the terms of your short term disability insurance policy, coverage may last for either a specified period of time (e.g., three months, six months, or up to a year) or until you are sufficiently recovered to return to work. Given the short-term nature of these disability benefits, unscrupulous insurers will sometimes delay benefits or deny benefits so as to exhaust a claimant’s interest in obtaining benefits.
Though short-term disability benefits are temporary, insurance companies are accustomed to denying these claims and making it difficult for disability claimants to obtain the benefits necessary to replace or supplement their income. Even if you have succeeded in obtaining short-term disability benefits, your insurer may challenge the duration of these benefits by terminating them prematurely.
ERISA Disability Insurance Claims
The Employee Retirement Income Security Act (ERISA) requires employer insurance plan providers to provide participants with important plan information. The Act was designed to protect employee rights including group disability insurance provided by an employer (not privately purchased policies). If an employee becomes disabled, they act as a participant or beneficiary and file a claim for benefits to the ERISA plan administrator, which is usually the insurer that issued the policy but can also be a variety of other people or entities.
An employee and/or their employer pay premiums for ERISA disability insurance. If an employee becomes disabled, they deserve monthly disability insurance benefits. Unfortunately, filing a claim for disability benefits is often not a smooth process. Insurance companies will look for and find a reason to deny a legitimate disability claim. While your company may have a human resources department and/or an employee in charge of benefits, these folks cannot replace the counsel of an experienced disability insurance lawyer.
If you file a claim and it’s denied, you will need to file an appeal. That is a very good time to hire an attorney so they can help with your appeal. If the insurer denies your appeal, your lawyer can help you file a lawsuit, as litigation under employer-provided group insurance policies is different from other types of insurance litigation. ERISA preempts state law claims, meaning federal law will apply, and you cannot get a jury trial and only have your case heard by a federal judge.
Houston Disability Insurance Lawyers
The attorneys at Berg Plummer Johnson & Raval, LLP are committed to helping people obtain the disability insurance benefits they rightfully deserve. Whether you are seeking benefits under a private disability policy or an employer or union plan, our attorneys will do everything we can to get you the money you are entitled to. We know how large insurance companies handle disability claims and we are prepared to represent our clients throughout the entire course of their claim, from submitting the initial application for benefits to handling administrative appeals to filing a lawsuit and reaching a favorable conclusion. Our disability insurance lawyers have years of experience successfully handling disability claims and we will fight to recover the benefits you rightfully deserve.
Given that many disability claimants have a limited budget and specific strategic goals, we work closely with clients to provide dynamic fee arrangements that are designed to cost-effectively achieve positive results.