Documentation and Denying a Claim

When a disability claim is denied, federal law requires the insurer provide the claimant with an explanation as to the reason for the denial. However, and in spite of this requirement, federal regulators felt that some insurers were complying with the technical form of the law, but not the purpose behind it. Consequently, new regulations will require insurers to provide claimants denied disability benefits the following:

• a discussion of any disagreement the insurer had with disability determinations from the Social Security Administration, other disability providers, or opinions of health care providers presented to the insurer for consideration;
• a copy of any internal rules, guidelines, protocols, standards or other criteria used to deny the claim; and
• a statement in the initial denial the claimant is entitled to a copy of all relevant documents, which currently is only required on appeal.

Responding to New Information

Presently, disability claimants do not learn about new evidence or rationales developed by an insurer while an appeal is under consideration until after the claim is denied. Under the new regulations, claimants would have the ability to review and respond to these new developments, as well as the opportunity to contest their application to a claim before a decision is made. This change is due to the view of federal regulators that a claimant cannot receive a full and fair review of an appeal if he/she cannot counter new evidence or rationales while an appeal is pending.

Violations of Claims Procedure Regulations

Finally, claimants currently have to exhaust all administrative remedies, i.e., the internal appeals process with the insurer, before they can sue. Claimants can attempt to abort this process by claiming the insurer is failing to substantially comply with claims procedures, but this is difficult to prove. The new rule would automatically deem administrative remedies exhausted if an insurer fails to follow claim procedures, allowing them to initiate litigation, unless one of these exceptions apply:

• the violation was minor;
• the violation did not prejudice the outcome;
• the violation was due to good cause or issues beyond the insurer’s control;
• the violation occurred within the context of a good faith exchange of information; or
• the violation does not reflect a pattern or practice of non-compliance.

This change should be an important shift for disability claimants, as a court’s review is often the best opportunity for receiving or retaining benefits, and the faster this review comes, the sooner benefits are paid.

Talk to a Disability Insurance Attorney

Disability benefits are indispensable to your financial security when you cannot work, and employing the services of an experienced disability insurance attorney is the best way to ensure you get the money you deserve. Farrell Disability Law is here to help you achieve that goal. Contact the Jacksonville law firm for a free consultation.

Resources:

thinkadvisor.com/2018/01/05/trumps-team-to-let-major-disability-claim-regs-tak

federalregister.gov/documents/2016/12/19/2016-30070/claims-procedure-for-plans-providing-disability-benefits

Offsetting by Private Disability Providers

Most private long-term disability policies, especially those offered as a group plan by an employer, include provisions that authorize the reduction of monthly benefits if income from other benefit programs is also collected by a policyholder. Examples of benefits that typically allow an insurer to offset monthly benefits include:

• SSDI;
• workers’ compensation;
• disability benefits offered under certain pension and retirement plans;
• compensation from an injury settlement; and
• benefits paid from another long-term disability policy.

The receipt of SSDI benefits is particularly important to insurers who want to ensure a disabled policyholder only receives the percentage of monthly earnings allowed under the policy, and not in excess of this amount (often 60 percent of an insured’s monthly earnings) due to receiving disability benefits from more than one source. Further, many policies require those filing a disability claim to pursue all other benefits for which he/she may be eligible, including appealing denials, and provide documentation confirming other benefits were sought. Most policies allow for a dollar-for-dollar reduction of SSDI benefits received by the insured, and obligate policyholders to reimburse the insurance company if he/she is given a lump-sum payment for back SSDI benefits following approval. Additionally, long-term disability benefits may also be further reduced by any SSDI benefits given to the recipient’s family. However, note that money received from the following sources will usually not reduce an insured’s disability monthly benefit:

• profit sharing plans;
• 401(k) plans;
• employee stock options;
• severance; and
• IRAs.

Offsetting under SSDI

The monthly benefit most SSDI recipients receive is typically not enough to support him/her, and most will seek other disability benefit options, or even part-time, occasional work, to supplement income. A person is only eligible to collect benefits under one Social Security program at any one time, and if a person qualifies for more than one Social Security program, he/she can choose the option with the higher benefit, but not both. The collection of other disability benefits does not generally affect SSDI benefits, unless it involves workers’ compensation. The combined payments from SSDI and workers compensation cannot exceed 80 percent of a person’s average income prior to their disability, and under Florida law, the workers’ compensation benefit will be reduced to stay within those limits. SSDI benefits will readjust to normal levels once workers’ compensation benefits are exhausted.

Get Help

Coordinating benefits from multiple sources is often financially necessary, but procedurally complicated. Handling just one disability claim is more than enough, but trying to juggle claims with different providers can quickly overwhelm most people. Instead of trying to navigate the disability process alone, work with the experienced disability firm of Farrell Disability Law. Farrell Disability Law has over 20 years representing clients in disability claims, and will work to get you the benefits you deserve. Contact the Jacksonville office for a free consultation.

Resource:

jdsupra.com/legalnews/erisa-can-a-court-invalidate-the-social-93509/

Disability insurance generally comes from three sources: employer-provided group policies, private individual disability policies and the benefits offered by the Social Security Administration. This coverage is intended to cover necessities, but not to replace the need for a person to work. Thus, while everyone should recognize the need to plan for this possibility and protect themselves accordingly, it is equally important to assess how these disability insurance options interact with one another in order to maximize benefit payouts and to determine how much additional income is necessary for financial stability.

Policy Review

The most important thing anyone with disability insurance coverage can do is review the terms of the policy. Clauses related to the percentage of income the insurance company will pay are a crucial provision that impact the level of benefits offered. For example, employer-provided disability insurance will typically pay up to only 60 percent of an employee’s salary, which leaves a significant amount that must be found elsewhere. A private disability policy could supplement this gap. In addition, how the policy defines “income” is also key information to know. Depending on an individual’s pay structure, the exclusion of bonuses or commission could greatly impact how much money an individual receives if he/she becomes disabled and consequently, whether the policy truly provides sufficient coverage. Further, many policies, both employer-provided and individual, place caps on the maximum amount the insurance company will pay each month, which could fall short of the percentage of income the policy is designed to replace. One final consideration for group or individual policies is how long the benefits are paid. Is it measured in months, to age 65, or beyond? Knowing this information is key to long-term financial planning.

Social Security Disability Insurance

The other alternative, Social Security Disability Insurance (SSDI), may seem like the easiest way to replace lost income in the event of a disability because it does not require an individual to pay a separate premium to obtain coverage, but merely to work a certain number of years. However, qualifying for SSDI is extremely difficult and time consuming, and almost always pays much less than any policy offered through an employer or purchased privately. Also, assuming a person does qualify, another important consideration in the overall picture of person’s disability coverage is the fact that receiving SSDI benefits can reduce the amount a person receives from group or individual policies. This adjustment offsets the total amount of money received, and could leave someone receiving less money than expected.

Contact a Disability Insurance Attorney

If you suffer from a disability that affects how much you can work, talk to a disability insurance attorney about your options for receiving benefits through SSDI or a disability insurance policy. Securing regular income during this difficult time is a top priority that deserves the careful and knowledgeable services of a disability insurance attorney. Farrell Disability Law helps clients throughout Florida and South Georgia get the money they need, and can assist you with your disability claims. Contact us for a free consultation.

Resource:

ssa.gov/pubs/EN-05-10029.pdf

One of the biggest issues concerning most disabled individuals, after finding adequate medical care, is figuring out how to financially support themselves. Social Security Disability Insurance (SSDI) is the avenue many take to obtain regular income. This option is available to individuals who worked in the past, but now find themselves unable to do so due to a mental or physical impairment. The application process to apply for disability benefits is fairly involved, and application can take days to complete depending on how extensive one’s work and/or medical history is. Consequently, when a letter denying disability benefits comes in the mail, the disabled applicant is often devastated. Thankfully, this is not the only opportunity someone has to make a disability claim. Anyone denied SSDI has the right to appeal, and the appeals process has many intermediate steps before a denial of disability benefits becomes final. Given that the approval rate for disability claims during the initial application stage is only 35 percent, the majority of those seeking SSDI will need to appeal. Thus, understanding the appeals process is very important to the successful award of disability benefits.

The Initial Application Review

While disability benefit eligibility is ultimately decided by the Social Security Administration (SSA), SSDI applications in Florida are funneled through the Florida Division of Disability Determinations, where an individual’s medical eligibility for benefits is decided. Assessments of non-medical eligibility (work history, for example) are made by the SSA. The processing time for this stage of an application is typically three to six months.

Reconsideration

Reconsideration is the first step in the appeals process, and must be requested within 60 days of a receiving a denial of SSDI benefits. If this 60-day window is missed, a new application must be filed. Reconsideration involves a review of an applicant’s file by a new examiner, but the same rules for determining whether to approve benefits apply, so approval at this stage is unlikely unless something was left off the initial application or new medical evidence is available for submission. Thus, any updates on a person’s medical condition, treatment or diagnosis should be forwarded to the SSA to give an applicant the best chance of success at this stage.

Administrative Law Judge Hearing

A hearing before an administrative law judge (ALJ) is the next step in the appeals process, and the one where an applicant is most likely to receive an approval of benefits. Again, a person has 60 days from the time a denial by the reconsideration examiner is received to request a hearing. Examiners affiliated with the SSA no longer have control over a decision, and an ALJ is permitted to make a determination based on evidence or testimony presented at a hearing. Having an attorney at this stage of the appeals process is very important to an approval of benefits by an ALJ, because the lawyer will know the types of evidence to submit, and the most effective way to present an applicant’s claim. Note that it is not uncommon for it to take over a year to a year and a half for a hearing to be scheduled.

Appeals Counsel

If a claim is still denied, the next step is to appeal to the SSA Appeals Council. Success at this stage is low because the Council only reviews whether the ALJ correctly applied the law. The Council does not review the substance of the disability claim itself. Typically, it takes six months to two years to receive a decision, and if the Council does think error occurred, it will refer the claim back to the ALJ.

Petition in Federal Court

The final step in the disability appeals process is to file a petition in federal court. At this stage, a lawyer is almost certainly needed if not already retained. The decision is entirely based on a brief filed with the court and in some cases, oral arguments before the judge. New evidence, testimony or documentation is not permitted. Federal courts are currently backlogged, and it can take well over a year for a decision to be made.

Work with a Disability Insurance Lawyer

The claim process for SSDI benefits can easily become overwhelming for an applicant, but an experienced disability insurance attorney can provide the guidance and expertise needed to get the benefits you deserve. Farrell Disability Law helps clients throughout Florida and South Georgia get the money they need. Contact us for a free consultation.

Resource:

floridahealth.gov/programs-and-services/people-with-disabilities/disability-determinations/index.html

The onset of a disability can come in many forms. Causes can range from major illness to a serious car accident that leaves the victim unable to perform the functions necessary for work and daily life. Having disability insurance in these circumstances often means the difference between maintaining stability, which frequently aids in recovery, and financial disaster. While people commonly associate these disabilities as permanent, one is much more apt to experience a short-term condition that requires some stoppage in work, but not a complete and permanent withdrawal from the work force. Certainly, the knowledge that one will return to work at some point in the near future takes some of the stress off an overwhelming situation, although going without income for even a short period of time places many in financial positions that are almost impossible to correct.

Short-term disability insurance coverage is designed to cover these circumstances by replacing a percentage of an insured’s income for a set period of time. Benefits are obtainable through an employer or by individual purchase directly from an insurance company. When this type of coverage is offered through an employer, the terms of the policy are rarely explained to covered employees, but crucial to the approval of a disability claim. Having this information may help to avoid needing to sue an insurance company for benefits wrongly denied.

Short-Term Disability in Florida

Many people assume that the state government has employer-mandated or state-sponsored short-term disability coverage for all working residents, but Florida does not. Florida only extends and evaluates disability claims for permanent disabilities through the Florida State Department of Health Division of Disability Determinations, which conducts disability determinations for Social Security disability benefits and the Medically Needy program. Employers are free to offer disability insurance coverage to employees, but are not required to do so. Outside of employers, individuals must purchase their own coverage. However, note that often times, preexisting conditions will not be covered until the policy has been in effect for certain period of time, usually 12 months. Thus, disability benefits from private insurance companies must be purchased in advance of the start of a debilitating condition, or benefits may be denied.

Filing a Disability Claim

If a person has coverage, and develops a disabling condition that requires an extended absence from work, a claim must be filed with the insurance company to receive income replacement benefits. This is true regardless of whether the coverage is through an employer or an individual insurance policy. Depending on the policy limits, insurance providers will typically pay up to 50-60% of a person’s regular earnings with a maximum dollar limit. Assuming a disability claim is approved, payments will begin once the elimination period is over. The elimination period is used by insurance companies to collect a certain amount of premium payments before having to pay out on a policy. Finally, all disability policies have payment duration limits. This means income replacement will only be paid for a specified period of time, which is selected by the policyholder at the time of purchase.

Contact a Disability Insurance Attorney

If your disability claim was denied, work with an experienced disability insurance attorney to appeal this decision and get the benefits you need. Farrell Disability Law helps clients throughout Florida and South Georgia fight wrongful denials of disability benefits. Contact the office for a free consultation.

Resource:

flarecord.com/stories/511038984-aetna-life-accused-of-wrongfully-denying-woman-s-claim-for-disability-benefits

Most people associate disability insurance benefits with the complete inability to work due to physical or mental impairments, but many individuals find they have some capacity, or desire, to work. This assumption is supported by the fact that the success or failure of an individual’s disability claim, regardless of whether the benefits are from a private insurance company or the Social Security Administration (SSA), hinges on an assessment of a person’s fitness to perform any type of work. The SSA, in particular, looks at this issue, and decides whether the claimant can return to the previous job full-time, or if another kind of work is a better fit as a result of the limitations imposed by the disabling condition. While it may seem that if someone is able to work to any extent, disability benefits are unavailable, this is not necessarily the case. The SSA does allow those receiving benefits to work, but enforces restrictions that anyone seeking or receiving Social Security Disability Insurance (SSDI) should be aware of to prevent a loss of benefits.

Employment and Filing a Claim

If someone is working in a reduced capacity due to disability, employment does not automatically preclude him/her from qualifying for SSDI. Eligibility for employed individuals seeking disability centers on how much they earn on a monthly basis. For 2016, if a person earns more than $1,130 on average per month, SSA considers the income substantial, and the disability application is effectively denied upon receipt. However, if an employer is making allowances, or providing special considerations, for a person’s disability, earning more than the monthly limit will not necessarily block a person’s disability claim. Special considerations are concessions an employer allows a disabled employee to take so he/she can continue to work. Examples of special considerations include more frequent breaks, reduced hours and additional time-off. Further, if the value of the work performed is less than the amount paid the disabled employee, the SSA will take the value of the work instead of the actual income to determine if the claimant is under the monthly income ceiling.

Employment While Receiving Benefits

This limitation on gainful employment continues after disability benefits are approved. Thus, a disabled individual could work and receive benefits as long as the income is under the $1,130 cap. In addition, the SSA has a program that assists individuals receiving disability to ascertain if any sort of work is possible by allowing disability recipients to participate in a trial work period. This program permits individuals on SSDI to test their ability to work over a nine-month time period, while still receiving full disability benefits, regardless of how much they make. All that is required is for the disabled individual to submit monthly work reports and continue to suffer from a disability. Any month where a benefit recipient earns more than $810, or works more than 80 hours if self-employed, is considered a trial work month. Disability benefit recipients have a total of 60 months to reach the nine-month trial work maximum. Once that limit is attained, the individual has another 36 months of extended eligibility for benefits for every month he/she earns less than $1,130.

Consult a Disability Insurance Attorney

If you have questions about disability benefits, do not try to wade through the complicated government regulations alone. Work with a disability insurance attorney experienced in negotiating the government process for obtaining disability benefits. Farrell Disability Law, a Florida law firm focusing on disability issues, is available to assist you with obtaining or keeping benefits you need and deserve. Contact the office for a free consultation.

Resource:

ssa.gov/planners/disability/dqualify5.html

Any illness, physical condition, or mental malady that requires someone to stop working is a devastating situation. Both financially and psychologically, holding steady employment is important to a person’s ability to live and function in society. Disability benefits, offered through private insurance policies and the Social Security Administration, are designed to replace some of the lost income. Anticipating the onset of these life-altering conditions is often impossible because they can appear suddenly and commonly take significant periods of time to diagnosis. Especially severe conditions that completely debilitate a person and/or lead to premature death require swift action in order to bring stability to someone experiencing this overwhelming situation. The disability insurance provided by the Social Security Administration (Social Security Insurance, or SSDI) includes a fast track option for those suffering from severe conditions so these individuals can receive benefits sooner. While most people will not qualify for this program, those that do need to know about its existence and how it works.

Compassionate Allowances Initiative

This program addresses providing disability benefits quickly to those clearly afflicted with conditions that meet disability standards. SSDI identifies certain serious conditions as automatically qualifying for disability benefits. The list of conditions was compiled in response to feedback from the public, advice from medical and scientific experts, and studies from the National Institutes of Health. Compassionate allowance determinations are made on objective medical assessments using much less medical evidence, which means the time SSDI needs to make a decision is greatly reduced. Public outreach hearings were held in the past, though no new hearings are presently scheduled, to educate the public on medical conditions that fall under the umbrella of illnesses identified as automatic disabilities. Examples of conditions included within the program are:

• traumatic brain injuries;
• Stroke;
• early onset Alzheimer’s;
• cancer; and
• autoimmune diseases.

SSDI adds conditions to the list on an annual basis, and works with advocacy groups to educate the public about the initiative generally.

Decision Parameters

Benefits awarded as a compassionate allowance are not part of a separate program, so the application process is same one used by everyone seeking disability benefits. However, applicants with these severe conditions are relieved of the burden of filling out work and education history questions on the application since this information has little bearing on the outcome. Disability evaluators are trained to spot conditions and diseases on the list of qualifying ailments, and if discovered, the application will be expedited. The typical turnaround time for a decision is then decreased to weeks, instead of the months or years that most applicants must wait. Some of the parameters that determine how long a decision will take are:

• how quickly SSDI receives an applicant’s medical records;
• if an examination by a physician selected by SSDI is necessary to assess the claim; and
• if the application is flagged for a compassionate allowance.

Note that receiving a compassionate allowance does not entitle the individual to receive more money, just a faster application processing time.

Contact a Disability Insurance Attorney

There is no guarantee that an application that should receive a compassionate allowance will be properly identified. However, if you work with a disability insurance attorney, the attorney will know how to fill out the application so SSDI is more likely to correctly identify you as worthy of being a compassionate allowance. If you live in Florida or South Georgia, Farrell Disability Law can provide the assistance you need to get the disability benefits you deserve. Contact us for a free consultation.

Resource:

ssa.gov/compassionateallowances/conditions.htm