How do I claim benefits under my LTD Insurance Policy?

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A long-term disability (LTD) plan is unlike social security programs such as SSI or SSDI.  Instead of filing a claim through the Social Security Administration, a long-term disability plan is insurance that you or your employer will purchase in order to protect you in case you become disabled (i.e. – cancer, car accident).  Because this is not an insurance plan outlined in social security law, it is important to understand your specific policy, or long-term disability agreement between your employer and its insurance company, as many of these plans may vary.  Generally, a long-term disability plan is one that provides replacement income in the event that you become disabled (during the course of your employment, for employer-based LTDs).  To receive this benefit, you or your employer must pay a monthly premium to the insurance company.  Our Long-Term Disability insurance lawyers in Tallahassee have negotiated and litigated LTD insurance claims against various insurers including The Standard, the Guardian, Prudential, Liberty Mutual and more.

A unique characteristic of LTD policies is how they define disability.  Under some group plans, you are considered disabled if you cannot perform “any occupation” in the economy.  However, other plans will define disability as the inability to perform your own occupation, which will transition to “any occupation” after two (2) years.

There are two different kinds of LTD policies: those covered under the Employee Retirement Income Security Act (ERISA), or group LTD policies provided by an employer; and individual LTD policies which can be negotiated directly between an employee and an insurance company to suit the needs of the insured.  It is important to understand the differences between these two LTD insurance options.  This article is meant to be a brief summary.  For an in depth (and free) consultation with an LTD appeal lawyer in Tallahassee, please call us today.

For both LTD insurance types, if your insurance company denies your claim, you must first appeal through your insurance company’s internal procedure.  If the insurance company reviews their decision and determines that it is justified based on your medical evidence, the following recourse is available to claimants based upon the type of LTD asset owned:

  • Individual LTD policies: holders may sue their insurance company in state court for breach of contract, negligence, bad faith, or other causes of action. Individual LTD policyholders’ cases are decided through jury.
  • Group (or ERISA) LTD policies: holders must sue in federal court where a judge will make a sole ruling on your case based upon evidence submitted at the administrative appeal (or internal appeal) stage with your insurance company.

It is important to submit all evidence for your case at the administrative appeal with your insurance company, as it is difficult to present new evidence for your case at the federal level. (Note: If you miss a deadline during your appeal with the insurance company, your chances of being able to file your ERISA claim in federal court are virtually nill.)  As Tallahassee LTD lawyers,we litigate in state and federal court depending upon the type of LTD policy.  However, the most important part of this representation is often at the administrative appeal so it is important to consult with your LTD lawyer early in the process.

For ERISA LTD policies, insurance companies’ decisions are assessed under the “abuse of discretion” standard.  In other words, the judge will evaluate your case based upon the evidence in your file and whether or not the evidence supported the insurance company’s original decision.  Individual LTD claims are evaluated differently.  In these cases, decisions are based upon whether or not the insurance company upheld its contract with the claimant.